^ 


Columbia  ©[nibergitpC.c.^^2 
in  t|je  Citp  of  ^to  l^ork 

CoIIegE  of  ^b?5fician£(  anb  burgeons! 


l^eference  l^ibrarp 


MEDICAL    DIAGNOSIS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicaldiagnosisOOIath 


MEDICAL    DIAGNOSIS 


BY 


ARTHUR      LATHAM, 

M.A.,  M.D.  (OxoN.),  F.R.C.P.  (Lond.) 

PHYSICIAN   AND   LECTURER   ON    MEDICINE,   ST.    GEORGE'S   HOSPITAL; 

AND 

JAMES      TORRENS, 

M.B.,  B.S.  (Lond.)'  M.R.C.P.  (Lond.) 

ASSISTANT   PHYSICIAN,   ST.    GEORGE's   HOSPITAL  AND    THE       ' 
P.^DDINGTON    GREEN    CHILDREN'S    HOSPITAL 


WITH    74    ILLUSTRATIONS,    19    IX    COLOUR 


Ni:\V   \OKK 

THE    MACMILLAX    CO. 
1915 


Printed  m   Great  Britain 


PREFACE 

Medicine  is  year  by  year  receiving  additional  help,  more 
especially  in  diagnosis,  from  the  ancillary  sciences.  In 
the  ordinary  text-books  on  medicine  space  does  not  permit 
of  adequate  reference  to  a  number  of  laboratory  methods 
— whether  bacteriological,  chemical  or  physical — side  by 
side  with  sufficient  clinical  and  pathological  detail.  Our 
pubhshers  informed  us  of  their  opinion  that  a  book,  in  which 
all  the  chnical  information  and  the  more  ordinary  laboratory 
details,  necessary  for  the  purpose  of  making  a  scientific 
diagnosis  in  medical  cases,  were  arranged  in  a  concise  and 
accessible  form,  was  constantly  sought  for  both  by  the 
student  and  the  practitioner.  At  their  request  we  have 
made  an  attempt  in  the  following  pages  to  meet  this  demand. 
We  have  availed  ourselves  freely  of  existing  text-books  and 
current  medical  literature  ;  but  do  not  feel  that  an  extensive 
bibliography  would  serve  any  useful  purpose  in  a  book  of 
this  size  and  scope. 

We  take  this  opportunity  of  expressing  our  indebtedness 
to  Dr.  Thomas  Lewis  for  his  permission  to  make  free  use  of 
his  book  on  "  Clinical  Disorders  of  the  Heart  Beat  "  in  the 
section  dealing  with  certain  forms  of  cardiac  irregularity  ; 
to  Dr.  Charles  ISlater  and  Dr.  E.  J.  Spitta  for  permission  to 
reproduce  thirteen  micro-photographs  from  their  athis  of 
bacteriology  ;  to  Dr.  Lindley  Hcott  for  permission  to  use 
fourteen  plates  from  his  atlas  of  urinary  deposits  ;  to 
Dr.  J.  W.  Linnell  for  the  pulse-tracings  in  the  cluipter  on 
diseases  of  the  heart  ;  to  Dr.  John  Parkinson  for  the  electro- 
cardiogram ilhistrating  heart-l)lock  ;    and  to  Miss  Seymour, 


vi  PREFACE 

of  St.  George's  Hospital,  for  the  preparation  of  a  number  of 
temperature  charts,  the  design  of  which  is  due  to  Miss 
Fullerton. 

Messrs.  Churchill  have  supplied  the  coloured  plates  of  the 
malarial  parasite  from  Dr.  Panton's  work  on  Clinical 
Pathology,  and  Figs.  71  and  72  from  Dr.  Aldren  Turner  and 
Dr.  T.  Graing3r  Stewart's  text-book  on  Nervous  Diseases. 

We  have  also  to  thank  Dr.  H.  W.  Warden,  house-surgeon 
at  St.  George's  Hospital,  for  the  beautiful  original  drawings 
which  illustrate  the  diseases  of  the  blood  and  the  diseases  of 
the  nervous  system,  etc.,  and,  finally,  Messrs.  Churchill  for 
their  long-suffering  patience  and  courtesy. 

A.  L. 
J    A    T. 

London,  W. 


TABLE    OF    CONTENTS 


PART    I. 

CHAITER 

I.     Specific  Ixfecti\t;  Diseases 
ActiiiomTCosis 
Anthrax     . 
Cerebro-Spinal  Meningitis 
Chicken-Pox 
Diphtheria 
Enteric  Fever 
Erysipelas . 
German  Measles 
Hydrophobia 
Glanders    . 
Gonorrhoea 
Influenza  . 
Measles 
Mumps 

Lobar  Pneumonia 
Relapsing  Fever 
Rheumatic  Fever 
Scarlet  Fever 
Small-Pox. 
Syphilis 
Tetanus     . 
Tuberculosis 
Typhus 
A^'hooping  Cough 

II.     Tropical  Diseases. 
Beri-Beri    . 
Gholera 
Dysentery. 
Kala-Azar. 
Leprosy 
Malaria 

Bhickwater  Fever 
Malta  Fever 
Plague 

Sleeping  Sickness 
Sprue 
Yellow  Fever 

III.     Certain-  Animal  Parasites. 
Cestoda 
Xematodes 
Trematodes 


1 

3 

4 

7 

9 

14 

24 

27 

28 

29 

32 

35 

38 

42 

43 

55 

56 

60 

66 

69 

78 

81 

111 

113 


116 
117 
120 
123 
124 
126 
131 
132 
133 
135 
136 
137 


140 
143 
149 


VUl 


TABLE   OF   CONTEXTS 


PART    II. 

CHAPTER  I'AGE 

I.     Diseases  of  the  Blood  axd  Blood-Formixg  Organs. 

Examination  of  the  Blood    .....      151 

Abnormalities  of  the  Blood.  ....      158 

Ansemia      ........      160 

Leukaemia.  .......      164 

Purpura 166 

Scurvy        .  .  .  .  .  .  .  .168 

•Splenic  Anaemia.  ......      168 

Lj-mphadeuoma  .  .  .  .  .  .169 

HaemopLiLia        .......      170 

II.     Diseases  of  the  Ductless  Glands. 

Diseases  of  the  Thyioid        .  .  .  .  .172 

Diseases  of  the  Thymus        .  .  .  .  .175 

Diseases  of  the  Suprarenal  Bodies  .  .  .      176 

Diseases  of  the  Spleen  .....      178 

.  Diseases  of  the  Pituitary  Body      .  .  .  .181 

III.     Disorders  of  Metabolism  and  Constitutional  Dis- 
eases. 
Diabetes  Mellitus  .  .  .  .  .  .185 

Diabetes  Insipidus       ......  189 

Gout 190 

Eickets 193 

Arthritis  Deformans    ......  195 

Fibrositis 197 


IV.     Sunstroke  and  Certain  Intoxications 
Sunstroke 
Alcoholism 
Moi-phini-sm 
Lead  Poisoning  . 
Chronic  Arsenical  Poisoning 
Chronic  Mercurial  Poisoning 


199 
200 
203 
204 
205 
206 


PART  III. 

Diseases    of    the    Cardio -Vascular    Stste:m   and 
Pericardium. 

The  Normal  Heart 207 

The  Significance  of  Displacement  of  the  Ajjex  Beat 
and  Alteration  in  the  Character  of  the  Cardiac 

Impulse 209 

The    Significance   of    Alterations  in    Cardiac   Dul- 

ness 210 

Significance  of  Alteration  in  the  Cardiac  Sounds  and 
their  Spacing  .......     212 

The  Significance  of  Cardiac  Murmurs  and  Thrills     .     213 
The  Pulse  and  Blood  Pressure       .  .  .  .218 

Acute  Endocarditis      ......     222 

The  Diagnosis  of  Valvular  Lesions  (Chronic  Endo- 
carditis)   227 

The  Diagnosis  of  Hypertrophy  and  Dilatation         .      234 


TABLE    OF   CONTEXTS 


IX 


CHAPTER 

I.  Diseases  of  the  Cardio- Vascular  System,  etc. — confd 

Myocardial  Degenerations     . 

Some  Forms  of  Cardiac  Irregularity 

Congenital  Heart  Disease 

Angina  Pectoris 

Aftections  of  the  Pericardium 

Arterio -Sclerosis 

Aortic  Aneurysm 

II.  Diseases  of  the  Respiratory  Tract  axd  Pleura 

Anatomy   ....... 

Examination  of  the  Chest  in  Health  and  Disease 

Cough  and  Sputum 

Di-seases  of  the  Larynx 

Bronchitis . 

Emphysema 

Bronchiectasis     . 

Fibrosi.s  of  the  Lung.? 

Mediastinal  Tumoiu",  in  -luding  New  G-rowth  of  Lung 

Bronclio-Pneumonia  and  Capillary  Bronchitis 

Abscess  of  the  Lung    . 

Gangrene  of  the  Lung 

Oedema  of  the  Lungs 

Bronchial  Asthma 

Pleurisy 

Pneumothorax    . 

III.     Diseases  of  the  Mouth,  Fauces,  (Esophagus   and 
Alimentary  Tract. 
The  Tongue  and  Mouth 
The  Tonsils 
The  Pharynx      . 
The  (Esophagus 
The  Stomach 
The  Intestines     . 
The  Peritoneum 


PART    IV. 

Diseases  of  the   Liver,  Biliary  Apparatus,   and 
Pancreas. 

Diseases  of  the  Liver  and  Bile  Passages. 

General  (.'ousideratious 

Jaundice    .... 

Acute  Yellow  Atropliy  oi  the  Liver 

Pylei)]ilcbiti8 

Livj'r  Abscess 

Congestion  of  the  Liver 

Cirrhosis  of  the  Liver 

New  (Jrowths  of  the  Liver    . 

(;alI-Stoues  ... 

Ciiolecystitis 

Cholangitis 
Diseases  of  the  Pancreas 


TABLE   OF   CONTEXTS 


C  HAPTTF. 
11. 


III. 


II. 


III. 


IT. 
V. 


EXAMIXATIOX    AND    AXAiTSIS    OF    UrIXE. 

General  Considerations  .... 

Nonnal  Urinaiy  Constituents 

Abnonnal  Urinary  Constituents    . 

Urinary  Deposits  ..... 

TTie  Bacteriological  Examination  of  the  Urine 

Diseases  of  the  Kidxet  axd  Ukixart  Appakatu: 
Xephi'itis    ..... 
Degenerations  of  the  Kidney 
Va~scular  Disturbances  of  the  Kidney.^ 
Pyelitis 

Urinary  Calculus 
Anvu'ia 
Ura-mia 

Movable  Kidney 
Renal  Tumoui's 

The  Estimation  of  the  Eenal  Function 
Inflammation  of  the  Bladder 

PAET   Y. 
Diseases  of  the  Xektous  System. 

AKAT03IICAE   AXD    PhTSIOLOGICAX    COXSEDERATIOXS 

The  Tracts  in  the  Central  Xervous  System 
Eeflex  Actions   ..... 
The  Yaso -Motor  System 
Cerebral  Localisation  and  Blood  Supply 
Electi'ical  Reactions  of  Muscles     . 
Evidence  of  Lesions  in  the  Motor  Path . 
Evidence  of  Lesions  in  the  Sensory  Paths 
•Segmental  Disti'ibution 
The  Craxial  Xerves. 
The  Olf actoiy  X'ei-ves . 
The  Optic  Xerve 
The  Oculo -Motor  Xerves 
The  Fifth  Cranial  Xerve 
The  Seventh  Cranial  X'erve 
The  Eighth  Cranial  Xerve    . 
The  X'inth  and  Tenth  Cranial  Xerves 
The  Eleventh  Cranial  Xerve 
The  Twelfth  Cranial  Xerve  . 

Xeuritis. 

Intei-stitial  Xeuritis     ...... 

Parench\Tnatous  X'euritis     .  .  .  .  . 

Acute  Toxic  Multiple  Xeuritis       .  .  .  . 

Lumbar  Puxctuee  axd  the  Cerebro-Spixal  Fluid 

Diseases  of  the  Beaix. 

Hydrocephalus  .... 

Vascular  Lesions  .... 

Cerebral  Palsies  of  Infancy  and  Childhood 

Tumours  of  the  Brain 

Abscess  of  the  Brain   .... 

Aphasia     ...... 

Apraxia     ...... 


408 
411 
417 
431 
439 


TABLE   OF   COXTEXTS 


XI 


CHAPTER 

YI. 


Diseases  of  the  Spixal  Cord. 


VII 


VIII 


IX. 


X. 


XI. 


XII. 


XIII. 


Hsemato-mvelia 

.     533 

Syringo-mTelia 

.      534 

Acute  Myelitis    .... 

535 

Tumours  of  the  Spinal  Cord 

537 

Diver's  Paralysis 

.      538 

Compression  of  the  Spinal  Cord    . 

.      538 

Syphilitic  Diseases  of  the  Xervous  Stste^i. 

Cerebro-Spinal  Syphilis         .....      .541 

Spinal  Pachymeningitis 

.      542 

Syphilitic  Meningo -Myelitis . 

.      543 

Tabes  Dorsalis    . 

.      544 

General  Paralysis  of  the  Insane     , 

.      548 

Gexekal  Diseases  of  the  Xervous  System. 

Disseminated  Sclerosis           .          .          .          .          .      .551 

Amyotrophic  Lateral  Sclerosis       ....      .553 

Subacute  Combined  Degeneration    of    the    Spinal 

Cord •    .556 

Acute  Polio -Myelitis    ......     .557 

Landry's  Paralysis       ......     559 

Familial  Diseases. 

The  Muscular  Dystrophies    .....     560 

Peroneal  Muscular  Atrophy 

562 

Friedreich's  Disea.se     . 

563 

Cerebellar  Ataxia 

564 

Familial  Spastic  Paraplegia. 

564 

Huntingdon's  Chorea  . 

564 

Amaurotic  Family  Idiocy     . 

564 

Myotonia  Congenita     . 

565 

Amyotonia  Congenita. 

565 

Myotonia  Atrophica    . 

565 

Disorders  of  Muscular  Fun'Ctiox. 

Myasthenia  Gravis       ......      566 

Paramyoclonus  Multiplex     .....      567 

Disorders  of  Motiox. 

Paralysis  Agitans         ......     569 

Chorea       .          .          .                    .          .          .          .     57o 

Tetany 572 

Occupation  Xeuroses  ......     573 

Certaix  Fuxctioxal  Diseases. 

Epilepsy 574 

Migraine 578 

The  Tics,  or  Habit  Spasms  .....     580 

Vaso-Motor  axd  Trophic  Diseases. 

Raynaud's  Disca.se       ......      582 

Intermittent  Claudication    . 

582 

Erj'thromelalgia.          .... 

583 

Angio-neurotic  (Fdema 

583 

Facial  Hemiatrophy    .... 

583 

Scleroderma        ... 

583 

Xll 


TABLE    OF   CONTENTS 


CHAPTER 

XIV,     Hysteria  and  Neurasthenia. 
Hysteria    .... 
Nem-asthenia 


585 
589 


PART   YI. 
Certain  Diseases  of  the  Skin. 

I.     Disorders  of  the  Cutaneous  Functions. 
Affections  of  the  Skin .... 
Disorders  of  the  Hair 
Disorders  of  the  Sebaceous  Glands 
Disorders  of  the  Sweat  Glands 

II.     Toxic  and  Organic  Diseases  of  the  Skin. 
Acne 

Cheiropompholyx 
Eczema 
Erythema 
Herpes 

Dermatitis  Herpetiformis 
Impetigo  Contagiosa   . 
Lichen  Ruber  Planus  . 
Lupus  Erythematosus 
PellagTa 
Pemphigus 
Pityriasis  Rubra 
Pityriasis  Rosea 
Pityriasis  Rubra  Pilaris 
Prurigo 
Psoriasis    . 
Sycosis 
Urticaria    . 
Certain  Drug  Eruptions 

III.     Certain  New  Formations. 
Corn 
Wart 
Cheloid 
Fibroma     . 

Molluscum  Contagiosum 
Xanthoma 
Ichthyosis 

lY.     Parasitic  Affections  of  the  Skin. 
Ringworm 
Favus 

Tinea  Yersicolor 
Erythrasma 
Acarus  Scabiei    . 
Pedi cuius  Capitis 

Pediculus  Vestimentorum  aut  Corporis 
Pediculus  Pubis 


592 
593 
593 
595 


595 
596 
596 
599 
602 
602 
603 
603 
604 
605 
606 
607 
608 
608 
608 
609 
611 
611 
612 


612 
612 
613 
613 
613 
614 
614 


614 
616 
616 
616 
616 
617 
617 
617 


MEDICAL    DIAGNOSIS 


PART    I 

CHAPTER    I 

SPECIFIC    INFECTIVE    DISEASES 

I.  ACTINOMYCOSIS. 

Definition.  A  chronic  infective  disease  due  to  the 
Actinomyces  bovis  (a  streptothrix  organism)  and  charac- 
terised by  the  presence  of  granulomatous  abscesses. 

Diagnosis.  The  infection  usually  occurs  in  the  mouth, 
particularly  in  relation  to  a  carious  tooth,  consequently  the 
abscess  is  most  frequently  seen  in  the  jaw  or  neck  ;  but  in 
view  of  the  fact  that  the  organism  may  be  inspired  or 
swallowed,  the  lesion  may  be  met  with  in  any  organ  of  the 
body.  A  case  has  been  recorded  of  actinomycotic  disease  of 
the  liver  secondary  to  infection  per  vaginam. 

In  making  a  diagnosis  the  history  of  exposure  to  infection 
is  very  important,  since  the  disease  is  almost  always  con- 
tracted by  chewing  infected  grain,  and  is  therefore  usually 
met  with  in  farm  labourers  and  cattle  tenders  or  in  threshers, 
who  may  inhale  the  infected  dust.  The  specific  lesion,  if 
superficial,  is  seen  as  a  brawny,  indurated  swelhng  which 
ultimately  suppurates  and  breaks  down  with  the  discharge  of 
pus,  in  which  arc  golden-brown  graiuilcs,  and  the  formation 
of  intractable  sinuses. 

The  diagnosis  can  only  be  established  with  certainty  by 
the  microscopical  examination  of  the  pus  from  one  of  the 
abscesses,  preferably  by  teasing  out  one  of  the  minute 
granules  mentioned  above,  when  the  streptothrix  filaments 
will  be  seen  as  Gram-positive  branching  threads  in  the  film 

M.D.  1 


2  MEDICAL  DIAGNOSIS 

preparations.  Prior  to  bacteriological  examination  actino- 
mycosis of  the  mouth  or  neck  may  be  indistinguishable 
from  sarcoma,  tertiary  syphilis,  chronic  septic  infection  or 
tuberculous  periostitis.  In  such  cases  valuable  information 
may  sometimes  be  gained  by  excision  of  a  small  piece  of  the 
affected  tissues  for  microscopical  examination  (biopsy),  by 
the  performance  of  the  Wassermann  reaction,  or  by  the  use 
of  the  special  methods  for  the  diagnosis  of  tuberculosis. 
In  addition  to  the  ordinary  form  of  actinomycosis  described 


Fig.  1. — Actinomyces  Hominis  in  pus  from  an  actino- 
mycotic abscess.     Magnification  X  1000. 

above,  visceral  actinomycosis  maj^  be  met  with  in  the 
following  varieties  : — 

Resjnratory  actinomycosis,  which  may  simulate  bronchitis, 
tuberculosis,  or  bronchiectasis,  and  in  which  the  diagnosis 
depends  on  an  examination  of  the  sputum  ;  while  the 
causative  organism  of  an  empyema  can  be  discovered  by  the 
bacteriological  examination  of  the  pus. 

Alimentary  tract  actinomycosis,  which  usually  commences 
by  ulceration  near  the  ccecum  and  which  secondarily  may 
lead  to  liver  abscess.  The  diagnosis  here  can  only  be  made 
by  exploratory  laparotomy  or  by  acupuncture. 


SPECIFIC   INFECTIVE   DISEASES  3 

Cerebral  actinomycosis,  which  is  indistinguishable  from 
any  other  form  of  brain  abscess  or  tumour. 

Cutaneous  actinomycosis,  which  may  simulate  a  cutaneous 
tubercuUde  or  syphilitic  ulceration.  The  estimation  of  the 
opsonic  index  before  and  after  exercise  and  the  performance 
of  Wassermann's  reaction  may  assist  the  diagnosis  in  these 
cases. 

II.  ANTHRAX. 

Definition.  A  specific  infective  disease  caused  by  the 
Bacillus  anthracis,  which  is  a  long  motile  Gram-positive 
organism. 

Varieties,    (i.)  Malignant  pustule,  acquired  by  inoculation. 

(ii.)  Wool-sorters'  disease,  acquired  by  inhalation. 

(iii.)  Splenic  fever,  acquired  by  ingestion.  ^ 

The  incubation  period  is  from  three  to  six  days. 

Diagnosis.  The  history  is  important  in  so  far  as  anthrax 
is  a  disease  of  herbivorous  animals  and  is  conveyed  to  man 
through  infected  wool,  hides  and  meat  ;  it  is  therefore 
especially  met  with  in  wool-sorters,  tanners  and  butchers. 

(i.)  The  Malignant  pustule  is  a  single  lesion  which  starts 
as  a  papule,  soon  vesiculates,  and  in  about  thirty-six  hours 
dries  to  a  black  scab,  which  is  situated  in  the  middle  of  a  red 
oedematous  area  and  is  surrounded  by  a  ring  of  secondary 
vesicles. 

Suppuration  does  not  occur.  Lymphangitis  and  glandular 
enlargement  follow,  but  there  are  no  constitutional  dis- 
tin-bances  for  from  two  to  four  days,  when  rigors,  pyrexia, 
and  vomiting  indicate  a  general  blood  infection.  In  un- 
treated cases  death  occurs  in  about  one  week,  but  for  some 
time  before  the  end  the  fever  abat(^s,  while  the  absence  of 
pain  throughout  is  an  important  feature. 

The  characteristic  bacilli  arc  abundant  in  the  vesicles,  and 
later  on  can  often  be  recovered  from  the  blood.  Occa-ionally 
the  distinctive  pustule  may  be  absent,  a  diffuse  brawny 
induration  alone  being  present  ;  these  cases  closely  resemble 
ordinary  cellulitis,  or  acute  spreading  colema.  The  absence 
of  pus  and  the  falling  temperature  are  important  diagnostic 
points  ;  while  the  most  likely  cause  for  spreading  oedema 
is  the  Bacillus  aerogem^s,  in  which  case  the  formation  of 
gas  causes  crepitation  in  the  tissues. 

1—3 


4  MEDICAL  DIAGNOSIS 

(ii.)  Wool-sorters'  disease  starts  suddenly  with  chill, 
prostration,  severe  pains  in  the  chest  and  back,  and  a 
temperature  of  102° — 103°  ;  there  is  some  bronchitis, 
dyspnoea,  cough  and  not  infrequently  a  blood-stained 
expectoration,  while  the  pulse  is  rapid  and  feeble.  The 
prostration  is  more  severe  than  the  signs  would  appear  to 
warrant,  and  death  may  ensue  in  from  twenty-four  hours  to 
one  week. 

(iii.)  Splenic  fever.  In  addition  to  the  symptoms  of 
profound  general  toxsemia  described  above,  the  patient  will 
have  severe  abdominal  pain,  diarrhoea,  vomiting,  and  a 
rapidly  enlarging  spleen.  Hcemorrhages  under  the  skin  and 
from  the  mucous  surfaces  may  precede  death. 


Fig.  2. — Bacillus  Anthracis   from   Bouillon   culture, 
showing  spore  formation.     Magnification  X  1000  . 

In  the  differential  diagnosis  of  the  two  latter  varieties  the 
history  of  possible  exposure  to  infection  is  of  paramount 
importance  ;  the  blood  and  urine  should  be  examined  for 
the  bacilli,  and  if  the  result  is  negative  some  of  the  blood 
should  be  injected  into  a  white  mouse,  when,  if  the  disease 
is  anthrax,  the  animal  will  die  in  a  fcAV  days  and  the  bacilli 
can  be  recovered  from  its  blood. 


III.  CEREBRO  SPINAL  MENINGITIS. 

A  specific  infective  disease  characterised  by  inflammation 
of  the  meninges  of  the  spinal  cord,  and  more  especially 


SPECIFIC  INFECTIVE  DISEASES  5 

of  the  base  of  the  brain,  and  caused  by  the  Diplococcus 
intracellular  is  of  Weichselbaum. 

Under  this  heading  will  be  included — 

(i.)  The  epidemic  form,  which  is  sometimes  accompanied 
by  a  purpuric  rash,  and  has  therefore  been  called  "  spotted 
fever." 

(ii.)  The  sporadic  form,  which  is  particularly  likely  to 
attack  young  infants,  and  which  is  then  commonly  known 
as  "  posterior  basic  meningitis." 

Diagnosis,  (i.)  The  epidemic  form.  The  onset  is  usually 
sudden,  with  very  severe  headache,  vomiting,  and  pains 
and  stiffness  in  the  back  of  the  neck  and  in  the  limbs. 
There  is  not  infrequently  a  rigor,  and  the  temperature 
rapidly  rises  to  103°  or  more,  and  subsequently  runs  a  c/)urse 
that  is  strikingly  irregular.  The  patient  is  usually  a  child 
or  a  young  adult.  Herpes  labiahs  is  common,  while  the 
presence  of  a  petechial  rash  is  suggestive.  There  is  early 
retraction  of  the  head,  which  rapidly  passes  into  opistho- 
tonos ;  at  the  same  time  muscular  rigidity  and  tremors 
become  evident.  Photophobia  and  ocular  paralyses,  usually 
of  the  external  recti,  are  common,  and  the  superficial  reflexes 
are  very  often  diminished  or  absent.  Mental  symptoms, 
even  maniacal  dehrium,  are  of  frequent  occurrence,  but 
commonly  coma  supervenes  after  three  or  four  days. 

There  is  an  invariable  leucocytosis,  which  persists  through- 
out the  entire  course  of  the  disease.  The  duration  of  the 
illness  may  be  from  a  few  hours  to  several  months,  and  the 
younger  the  patient  the  more  probable  is  a  fatal  issue. 

Several  clinical  varieties  are  recognised  in  addition  to  the 
ordinary  form  described  above. 

(a)  A  malignant  form,  in  which  the  pyrexia  is  moderate 

and  the  pulse  slow,  while  a  purpuric  rash  is  particularly 

common.     In  this  variety  death  occurs  in  from  twelve 

to  seventy-two  hours. 

(6)  An  abortive  form,  in  which  the  patient  enters  upon  a 

rapid  convalescence  about  the  fifth  day,  notwithstanding 

previous  meningeal  symptoms  of  extreme  severity, 
(c)  An   intermittent  form,  in  which  there  are  periodic 

exacerbations  of  pain  and  temperature  for  many  weeks. 

(ii.)  The   sporadic    form    or    posterior    basic    meningitis. 


6  MEDICAL  DIAGNOSIS 

Apart  from  the  absence  of  an  epidemic,  the  infrequency 
of  a  skin  eruption,  and  the  fact  that  the  vast  majority 
of  the  cases  occur  in  infants,  the  course  of  this  disease  is 
very  similar  to  that  of  the  epidemic  form  described  above. 
Although  the  mortality  is  extremely  high,  the  course  of  the 
disease  tends  to  be  chronic.  Extreme  emaciation  of  the 
patient  is  a  distressing  feature  of  these  cases.  In  patients 
who  are  sufficiently  young  the  bulging  anterior  fontanelle 
bears  witness  to  the  rapid  rise  in  intracranial  tension. 
Optic  neuritis  is  rare. 

Kemig's  sign  is  said  to  be  of  special  diagnostic  import 
in  basic  meningitis.  This  sign  consists  in  the  inability 
of  the  patient  to  extend  the  legs  on  the  thighs  when  the 
thighs  have  been  first  flexed  on  the  abdomen.  In  our  ex- 
perience the  value  of  this  sign  has  been  overestimated  and  is 
largely  restricted  to  cases  in  which  the  patient  is  a  young  child. 

Lmnbar  puncture  is  the  quickest  and  most  satisfactory 
method  of  estabhshing  the  diagnosis.  The  object  of  this 
procedure  is  to  withdraw  some  of  the  cerebro-spinal  fluid 
from  the  lumbar  region  of  the  theca  spinalis.  The  cerebro- 
spinal fluid  is  under  pressure  and  turbid  or  even  pundent. 
It  should  be  collected  in  a  sterile  vessel  and  submitted  to 
microscopical  examination  without  delay.  The  cellular 
content  is  found  to  be  much  increased,  the  cells  are  poly- 
morphonuclear leucocytes,  and  the  characteristic  organism, 
an  intracellular  Gram-negative  diplococcus,  will  usually 
be  visible  in  the  films  of  the  centrifiigalised  deposit.  It  some 
of  the  fluid  is  inoculated  on  to  the  surface  of  an  agar  tube, 
freshly  smeared  with  human  blood  and  incubated  at  37°  C, 
a  growth  of  the  organism  can  usually  be  obtained. 

The  diseases  most  likely  to  be  confounded  with  cerebro- 
spinal meningitis  are  the  following  : — 

Tiiherculous  Meningitis.  This  is  not  so  common  in  the 
first  year  of  life  and  does  not  occur  apart  from  tuberculosis 
elsewhere,  the  signs  of  which  may  be  susceptible  of  recogni- 
tion :  retraction  of  the  head  is  less  marked,  and  the  course 
is  usually  shorter  than  in  cerebro-spinal  meningitis  ;  further, 
tubercles  may  be  present  on  the  choroid,  and  the  fluid  from 
the  lumbar  puncture  is  limpid  and  sterile  and  contains  an 
excess  of  lymphocytes. 


SPECIFIC   INFECTIVE   DISEASES  7 

Enteric  Fever.  The  absence  of  a  leucocytosis  and  the 
presence  of  Wiclal's  reaction  at  the  end  of  the  first  week 
serve  readily  to  differentiate  this  disease  from  cerebro-spinal 
meningitis. 

Pneumonia  usually  presents  suggestive  signs  in  the  chest, 
and  such  extreme  rapidity  of  respiration  is  rare  in  meningitis  ; 
but  pneumonia,  and  especially  apical  pneumonia  in  children, 
is  often  accompanied  by  meningismus,  which  may  closely 
simulate  meningitis  ;  further,  pneumococcal  pneumonia 
may  be  accompanied  by  pneumococcal  meningitis,  and 
cerebro-spinal  meningitis  is  occasionally  comphcated  by 
pneumonia  due  to  the  Diplococcus  intracellularis. 

Lumbar  puncture  will  settle  the  diagnosis,  for  the  cultural 
characteristics  of  the  two  organisms  differ  widely,  tl^ough 
polymorphonuclear  leucocytes  will  be  present  in  both 
cases. 

Septic  meningitis  does  not  occur  apart  from  some  septic 
focus,  such  as  otitis  media  or  mastoid  disease. 

IV.  CHICKEN  POX. 

Defmition.  A  specific  infective  disease,  the  causative 
organism  being  as  yet  undiscovered,  which  is  characterised 
by  a  vesicular  eruption. 

Incubation  Period.  The  incubation  period  of  chicken-pox 
is  rather  variable,  but  fourteen  days  may  be  considered  an 
average  time. 

Diagnosis.  The  disease  usually  attacks  children  of  from 
two  to  six  years,  and  one  attack  nearly  always  confers 
complete  immunity.  There  is  sometimes  a  trifling  malaise  or 
pyrexia  for  about  t^\'enty-four  hours,  but  often  the  first  thing 
observed  is  the  aj^pearance  of  a  sparse  papiUar  eruption, 
most  evident  about  the  thorax  and  abdomen.  In  a  few 
hours  the  papules  develop  into  vesicles,  the  contents  of  which 
become  tur])id  after  two  days  and  dry  up  into  brown  scabs, 
without  suppuration,  a  few  days  later.  These  scabs  drop 
off  about  the  tenth  day,  and  do  not  leave  a  scar  unless 
secondary  infection  has  been  permitt^'d,  as  by  scratching. 
The  spots,  which  do  not  become  confluent,  appear  in  little 
showers  at  intervals  of  about  twelve  hours,  and  mav  thus  be 


8  MEDICAL  DIAGNOSIS 

seen  in  all  stages  of  development  at  one  and  the  same  time. 
They  frequently  occur  on  the  mucous  membranes,  and  vary 
in  total  number  from  ten  or  twelve  to  several  hundreds. 
When  the  spots  are  very  numerous  the  severe  itching  causes 
great  distress.  A  shght  rise  in  temperature  is  liable  to  occur 
as  each  successive  crop  of  spots  makes  its  appearance. 

In  very  exceptional  cases  the  vesicles  of  chicken-pox  may 
become  bullous  and  simulate  pemphigus  for  a  few  days.  A 
grave  but  happily  rare  sequel  of  chicken-pox  is  a  condition 
known  as  "  Gangrenous  Dermatitis,"  in  which  there  is  a 
spreading  superficial  gangrene  of  the  skin.  A  fatal  result, 
due  presumably  to  septic  absorption,  ensues  in  the  majority 
of  such  cases. 

It  should  be  remembered  that  when  chicken-pox  attacks 
an  adult  it  may  be  attended  by  much  more  severe  constitu- 
tional disturbance  ;  a  temperature  of  104°  is  by  no  means 
uncommon,  and  the  spots  may  be  so  numerous  as  practically 
to  cover  the  whole  body. 

Differential  Diagnosis.  Chicken-pox  must  not  be  con- 
founded with  the  following  conditions  : — 

(i.)  Small-pox.  Attention  to  the  following  points  should 
serve  to  prevent  this  mistake  : — 

In  the  absence  of  an  epidemic  small-pox  is  most  unlikely. 
In  small-pox  the  onset  is  attended  by  severe  constitutional 
disturbance  ;  the  rash  appears  on  the  third  day  and  all  at 
once,  while  it  does  not  become  vesicular  till  the  sixth  day, 
and  it  is  most  marked  on  the  face  and  hands.  Prior  to  their 
appearance  the  papules  can  be  felt  as  shotty  nodules  under- 
neath the  skin.  After  the  rash  has  appeared  the  tempera- 
ture falls  for  a  while  until  suppuration  in  the  vesicles  causes 
it  to  rise  again  on  the  eighth  or  ninth  day,  while  just  before 
the  vesicles  become  purulent  they  are  definitely  umbilicated. 
Lastly,  there  is  a  red  inflammatory  areola  around  the  pocks. 

(ii.)  Varioloid,  or  Small-pox  in  the  vaccinated.  In  this 
condition  the  presence  of  vaccination  marks  and  an  epidemic 
of  small-pox  is  of  importance,  while  the  invasion  lasts  longer 
than  in  chicken-pox  and  the  rise  in  temperature  is  more 
abrupt.  The  vesicles  are  preceded  by  shotty  papules  and  are 
most  likely  to  occur  in  one  eruption  on  the  face  and  hands, 
while  the  temperature  usually  falls  by  crisis  as  soon  as  the  rash 


SPECIFIC   INFECTIVE   DISEASES 


has  appeared,  and  does  not  show  shght  exacerbations  ^^'ith 
the  appearance  of  successive  crops  as  happens  in  varicella. 

(iii.)  Herpes  Zoster.  The  vesicles  here  follow  accurately 
the  distribution  of  a  sensory  nerve-root,  and  there  is  consider- 
able local  pain. 

V.  DIPHTHERIA. 

Definition.  A  specific  infective  disease  due  to  the  KJebs- 
Loeffler  bacillus,  characterised  by  inflammation  of  the  naso- 
pharynx, fauces  or  larynx, 
and  leading  to  coagulation 
necrosis  and  the  formation  of 
a  false  membrane  at  the  site 
of  infection. 

Etiology.  Diphtheria  i^^ 
particularly  a  disease  of 
children  under  ten  years  of 
age.  It  occurs  in  epidemics, 
but  is  also  endemic  in  all 
large  towns,  while  a  certain 
number  of  sporadic  cases 
occur  in  which  all  efforts  to 
trace  the  source  of  infection 
are  fruitless. 

The  Klebs-Loeffler  bacillus 
is  a  small  rod-shaped  bacillus 
which  stains  irregularly  with 
all  ordinary'  stains.  It  grows 
well  on  all  ordinary  culture 
media,  but  especially  well  on 
Loeflfler's  inspissated  blood 
serum.  The  bacillus  does 
not  enter  the  blood  stream  ; 
the  symptoms  therefore  are 
due  to  tf)x;rniia. 

Incubation  Period.  Usually  two  days  (thirty-six  hours  to 
seven  days). 

Course.  The  invasion  may  be  abrupt,  with  shivering, 
vomiting,  etc.,  but  more  often  it  is  gradual,  with  malaise, 
headache,  and  loss  of  appetite. 


1 

1 

r 
1 

7 

los' 

l(Hf 
103' 
102" 
101' 
lOO" 
39° 
38' 

96' 
''•95' 
MO 
130 
120 
no 
100 
90 
SO 
70 

eo 

55 

45 
35 

15 

M    E 

M    E 

M   E 

M  E 

M   E 

M  E 

M  E 

M  e 

ME 

/ 

A 

:^ 

^      \ 

J' 

A 

^\  \ 

,,A 

--- 

•-- 

.i.. 

■  ■is 

\i^: 

/• 

,v- 

^•'^• 

... 

V: 

i*^ 

h 

^  >-V 

/ 

\^ 

^  : 

r 

: 

v 

■T» 

^ 

^-^ 

/^ 

v*" 

*^ 

—— 

_ 

Fig.  3.  Chart  from  a  case  of  Diphth-iia 
treated  with  antitoxin  at  the  beginning 
of  the  second  day.  Note  the  rapidity 
of  the  pulse  in  contrast  to  the  slight 
pyrexia. 


10  MEDICAL  DIAGNOSIS 

Soreness  of  the  throat  may  be  trifling  at  first ;  indeed,  it  is 
frequently  not  complained  of  at  all  by  small  children. 
Examination  will  reveal  swelling  and  redness  of  the  fauces, 
with  often  a  patch  of  dirty,  greyish-white  membrane  on  a 
tonsil  or  on  the  soft  palate  or  faucial  pillars.  The  membrane 
shows  a  great  tendency  to  spread  to  neighbouring  parts. 
The  glands  about  the  angles  of  the  jaw  tend  to  be 
enlarged.  If  the  membrane  is  picked  ofi^,  a  bleeding 
surface  is  exposed,  which  rapidly  becomes  re-covered  by 
membrane. 

The  child  soon  presents  the  dull,  earthy  pallor  of  pro- 
found toxaemia. 

The  temperature  is  not  high,  usually  between  101°  and 
102°,  but  the  pulse  is  very  rapid,  about  135  per  minute,  and 
of  poor  quality.  The  importance  of  this  pulse  temperature 
ratio  is  very  great. 

Myocardial  degeneration,  as  shown  by  cardiac  dilatation, 
may  be  evident  at  an  early  stage. 

The  urine  is  of  the  febrile  type,  high  coloured  and  scanty, 
and  slight  albuminuria  is  so  common  as  to  be  regarded  as  a 
usual  manifestation  of  the  disease. 

The  knee-jerks  at  first  are  increased,  but  in  a  few  days 
become  diminished  or  even  absent. 

Varieties,  (i.)  Fmicial,  as  described  above. 

(ii.)  Laryngeal.  Usually  a  comphcation  of  the  faucial 
variety,  but  it  may  occur  as  the  sole  affection.  The  signs  of 
laryngeal  involvement  are  laryngeal  stridor,  increasing 
cyanosis  and  dyspnoea,  restlessness  and  increasing  rapidity 
of  the  pulse  rate,  and  intercostal  recession  and  sue  king-in  of 
the  lower  ribs  on  each  inspiration. 

(iii.)  Nasal  di'phiheria  is  usually  an  accompaniment  of 
ordinary  or  faucial  diphtheria,  but  may  exist  alone. 

The  constitutional  disturbance  in  this  last  variety  may  be 
slight  ;  a  nasal  discharge,  and  especially  a  blood-stained 
nasal  discharge,  may  be  the  only  sign.  It  is  not  too  much  to 
say  that  every  chronic  nasal  discharge  in  children  should  be 
cultivated  for  the  Klebs-Loeffier  bacillus.  The  course 
tends  to  be  very  protracted. 

{rv.)  Diphtheria  of  the  Conjunctiva.  A  membranous  con- 
junctivitis may  be  due  to  diphtheria. 


SPECIFIC   INFECTIVE   DISEASES  11 

Complications.  Complications  are  not  numerous  :  the 
most  important  are  : — 

(i.)  Heart  Failure.  This  may  occur  as  early  as  the  third 
day  of  the  disease,  but  is  most  to  be  feared  in  the  second 
week.  It  is  due  at  this  stage  to  toxic  myocardial  degenera- 
tion and  may  manifest  itself  with  alarming  suddenness  ; 
arrhythmia  develops,  with  increasing  rapidity  and  feebleness 
of  the  pulse,  and  is  quickly  followed  by  the  signs  of  extreme 
cardiac  dilatation  {vide  p.  236). 

The  effect  of  the   toxins  on  the  heart  muscle  mav  be 


\ 


Fio.  4. — Bacillus  Diphtheriic  in  Nasal  Secretion. 
Marmification  X  1000. 


apparejit  for  many  weeks  in  a  case  in  which  the  course  luis 
otherwise  been  satisfactory.  The  symptoms  Ivere  will  l)e 
irregularity  of  the  cardiac  action,  especially  after  exertion, 
alteration  of  the  spacing  of  the  heart  sounds  either  in  the 
direction  of  a  "  tic-tac  "  rhytinn,  caused  by  prolongation 
of  systole  at  the  expense  of  diastole,  or  the  ojjjjosite  state 
of  affairs  when  the  sounds  come  close  together  and  the 
<liastolic  ])aus('  is  unduly  ])i(»longed. 

Alter  the   third  week    heart   failure    may    nuinifest  itself 
in    yet   another    nuiiuier     that    is    to    say    by    neuritis    or 


12 


MEDICAL  DIAGNOSIS 


post-diphtheritic  paralysis  affecting  the  vagus  nerve.  It  is 
extremely  rare  for  this  to  occur  at  all,  and  rarer  still  for  it  to 
happen  as  an  isolated  palsy. 

(ii.)  Post-diphtheritic  paralysis  occurs  in  15  per  cent, 
of  all  cases,  and  its  incidence  is  in  no  way  determined  by 
either  the  severity  of  the  initial  infection  or  the  use  of 
antitoxin.  It  appears  as  a  rule  about  the  end  of  the  third 
Qr  during  the  fourth  week. 

The  muscles  paralysed  are  usually  affected  in  the  following 
order  : — 

(a)  The    Soft    Palate.     In 


severe  cases  this  permits 
regurgitation  of  liquids 
through  the  nose,  and  in 
milder  cases  imparts  a 
nasal  tone  to  the  voice, 
most  noticed  in  such 
words  as  "pig,"  which  is 
pronounced  as  if  spelled 
pihgh. 

(b)  The  Internal  Ocular 
Muscles.  This  results  in 
loss  of  power  of  accom- 
modation of  the  pupil, 

(c)  The  Extensors  of  the 
Legs.  This  produces  a 
drop  foot,  and  may  pre- 
vent standing  altogether. 

(d)  The  External  Ocular  Muscles.     This  causes  strabis- 
mus (usually  convergent). 

(e)  Involvement  of  the  phre?iic  nerves,  the  intercostals,  and 
the  vagus.     This  condition  is  a  rare  one. 

It  should  be  noted  that  diphtheria  is  not  infrequently 
first  diagnosed  when  paralysis  occurs,  the  faucial  affection 
having  been  so  mild  as  to  escape  notice. 

(iii.)  Bro7icho-pneu7nonia,  caused  by  inhalation  of  septic 
particles  or  by  spread  of  the  membrane  down  the  trachea. 
It  is  most  frequent  in  laryngeal  cases  and  gives  the  usual 
signs  of  Broncho -pneumonia  {q.v.}. 

(iv.)  Otitis  Media.  This  is  liable  to  occur  after  any  septic 
infection  of  the  fauces,  and  the  possibility  of  the  Klebs- 


FiG.  5.— Bacillus  Diphtherise.  Seventy- 
two  hours  culture  on  gelatine  at  21°  C 
Magnification  x  1000. 


SPECIFIC   INFECTIVE   DISEASES  13 

Loeffler  bacillus  being  present  in  a  case  of  otorrhoea  must 
be  borne  in  mind. 

(v.)  Acute  Nephritis.  This  complication  is  extremely 
rare  and  must  not  be  confounded  with  albuminuria,  which 
is  almost  invariable.  The  presence  of  blood  and  casts  in  the 
urine  renders  mistake  impossible. 

Diagnosis.  The  history  of  exposure  to  infection,  or  of 
other  "sore  throats  "  in  the  same  house,  is  important  ;  but 
the  only  certain  method  of  diagnosing  diphtheria  is  to  isolate 
the  characteristic  organism  from  the  nose  or  throat.  For 
this  purpose  a  swab  is  taken  from  the  throat,  or  if 
any  membrane  is  present  a  piece  is  picked  off  with 
forceps. 

With  this  an  even  film  is  spread  at  once  on  a  clean  glass 
slide  by  gently  rubbing  the  swab  or  membrane  backwards 
and  forwards  ;  it  is  fixed  by  passage  through  a  Bunsen 
flame  and  stained  by  Neisser's  method,  or  with  methylene 
blue,  and  examined  under  an  oil-immersion  lens. 

In  many  cases  a  skilled  observer  can  make  a  diagnosis 
from  the  fresh  films,  but  the  bacilH  become  so  pleomorphic 
when  okler  than  twenty-four  hours  that  considerable 
experience  is  necessary  for  their  identification.  Again, 
numbers  of  other  organisms  are  always  present.  It  is  there- 
fore usually  desirable  to  obtain  a  culture  of  the  organisms 
present.  Accordingly  a  culture  tube  of  inspissated  blood 
serum  is  inoculated  from  the  swab  or  membrane  and  incu- 
bated for  twelve  to  fifteen  hours  at  37°  C,  at  the  end  of 
which  time  a  practically  pure  growth  of  Klebs-Loeffler 
bacilli  will  be  obtained  if  diphtheria  is  present. 

A  membranous  infection  of  the  fauces  may  be  produced 
by  either  streptococci  or  pneumococci,  and  conversely  in 
true  di])htheria  membrane  is  sometimes  entirely  absent, 
while  the  bacillus  of  Hoffmann  may  produce  a  condition 
clinically  indistinguishable  from  diphtheria.  Bacteriologi- 
cally  Hoffmann's  bacillus  does  not  grow  quite  so  quickly 
on  Loefflers  blood  serum  as  the  <li])htlu'ria  bacillus  ;  it  is 
shorter  and  broader,  it  has  not  got  so  definitely  beaded 
an  appearance  and  usually  shows  a  central  septum.  It 
does  not  give  polar  staining  by  Neisser's  method.  Strepto- 
cocci and  pneumococci  do  not  appear  in  culture  on  Loeffler's 


14  MEDICAL  DIAGNOSIS 

blood  serum  for  six  or  eight  hours  after  the  colonies  of  the 
diphtheria  bacillus  are  present. 

Follicular  tonsillitis  (vide  also  p.  316)  has  a  more  sudden 
onset  than  diphtheria  ;  the  exudate  is  usually  yellowish 
and  localised  to  the  tonsillar  crypts  ;  the  patches  of  exudate 
do  not  specially  tend  to  run  together.  The  flushed  face, 
stiff  and  painful  neck,  and  high  temperature  are  all  unlike 
diphtheria,  and  the  toxsemia  is  not  nearly  so  profound.  A 
seemingly  simple  tonsillitis,  however,  may  really  be  due  to 
the  diphtheria  bacillus,  and  all  such  cases  should  be 
examined  bacteriologically. 

After  the  operation  of  removal  of  the  tonsils  the  stumps 
are  coated  for  some  days  with  a  greyish  slough,  which  may 
cause  apprehension  in  the  mind  of  one  not  familiar  with 
the  fact. 

Vincent's  angina,  which  is  commonly  mistaken  for  diph- 
theria, presents  the  following  picture  : — A  deep  sloughy 
ulcer  covered  with  a  yellowish  membrane,  situated  as  a  rule 
on  or  behind  one  tonsil  and  often  accompanied  by  severe 
constitutional  disturbance  and  a  temperature  of  103°  or 
more.  The  diagnosis  can  readily  be  established  by  examin- 
mg  a  fresh  film  stained  with  methylene  blue,  when  the 
presence  of  large  fusiform  bacilli  and  numerous  spirilla 
prove  the  case  to  be  one  of  Vincent's  angina. 

Scarlet  fever  in  the  early  stages  maybe  difficult  to  diagnose 
from  diphtheria,  and  it  should  be  remembered  that  the  two 
diseases  may  co-exist. 

Bacteriological  examination  of  the  throat  will  settle  the 
question.  The  more  sudden  onset  with  rigor  and  vomiting, 
the  higher  temperature,  and  the  even  more  rapid  pulse 
(temperature  104°  ;  pulse  160)  are  greatly  in  fa v^our  of  scarlet 
fever,  while  in  thirty-six  hours  the  characteristic  rash  should 
make  its  appearance  (vide  also  "  Scarlet  Fever,"  p.  64). 

VI.  ENTERIC  FEVER. 

Definition.  A  specific  infective  disease  due  to  the  Bacillus 
typhosus  of  Eberth,  and  characterised  by  a  septicaemia 
associated  with  ulceration  of  the  intestine,  inflammation 
of  the  mesenteric  glands,  enlargement  of  the  spleen,  bron- 
chitis, and  a  papular  eruption. 


SPECIFIC   INFECTIVE  DISEASES 


15 


Incubation  Period.    Fourteen  days  (three  to  twenty-three 

days). 

Course.  The  onset  is  nearly  always  gradual,  the  patient 
complaining  of  headaehe,  chilliness,  and  general  malaise. 
Epistaxis  is  fairly  common,  while  vague  abdominal  discom- 
fort and  diarrhoea  are  frequently  met  with.     In  three  or 


c 

1 

101' 
105' 
10*' 
103' 
lOZ- 
101' 
100" 
99° 

M    E 

M    E 

M  e 

M   E 

M    E 

M  E 

ME 

M  E 

M   E 

M   E 

M   E 

M  t 

M  E 

ME 

M  E 

M   E 

M   E 

M  E 

M  E 

H   E 

M  E 

■l 

/" 

■\ 

\ 

/ 

V^ 

A 

;/ 

1 

V 

V   ^ 

\/' 

y^ 

y^ 

r 

^ 

S      , 

iA 

A 

k 

/ 

V- 

V 

V 

^  \ 

\ 

A 

A 

:A 

/ 

V 

J 

y 

A 

/I 

\- 

V: 

w 

VA 

.4- 

.m. 

.m. 

.-. 

"^" 

■  MM 

... 

... 

... 

.— . 

.m. 

... 

•w 

... 

■  »■ 

-*• 

•  *• 

y.. 

if 

ar 

■• 

V 

.as' 

1*0 
130 
120 

no 
100 
90 

to 

70 
60 

rso 
ss 

45 
3i 
33 

^13 

■J 

7 

f' 

A 

■A 

vl 

/ 

\^ 

J 

/ 

V 

V 

-^ 

^ 

wA 

^'^ 

kA 

A 

J 

\f 

v 

V 

Vc 

V    ' 

,/ 

\^ 

,^ 

: 

*T" 

'-• 

••- 

■  •■ 

•T- 

•♦• 

"♦• 

.*• 

•»• 

•T* 

■ 

... 

.*. 

.*. 

.;. 

•^• 

■** 

'V 

.  w . 

■«■ 

■*• 

; 

' 

■ 

■A 

r 

r^ 

A 

/ 

^.    . 

^^ 

~^ 

A, 

■    * 

J- 

\L 

V 

^ 

_ 

__ 

_ 



^^j^ 

^^ 

Fig.  6.— Typical  Chart^of  a  mild  case  of  Enteric  Fever. 

four  days  the  patient  will  feel  so  ill  tliat  he  is  compellcil  to 
go  to  bed.  The  temperature  rises  two  degrees^each  evening, 
ren\itting  one  of  these  the  following  morning,  until  a  lieight 
of  103^  or  104°  is  reached.  The  pulse,  at  first  full  and 
bounding,  has  by  now  become  remarkably  soft  (even 
dicrotic),  and  its  rate  is  about  100  per  minute.  The 
tongue  at  first  is  moist,  with  thick  white  fur  on  the  dorsum 
and  a  red  tip  and  sides,  but  later  on  it  becomes  dry  and 
cracked.     The  abdomen   is    usually    somewhat    distended, 


16  MEDICAL   DIAGNOSIS 

and  there  may  be  some  tenderness  in  the  neighbour- 
hood of  the  caecum.  At  the  end  of  the  first  week  it  is 
often  possible  to  feel  the  spleen  at  or  below  the  costal 
margin.     More  or  less  bronchitis  is  almost  invariable. 

From  the  fifth  to  the  seventh  day  a  scarlatiniform 
erythema  may  occasionally  complicate  the  diagnosis,  but 
the  characteristic  rash  is  rarely  met  with  until  the  seventh 
day.  It  consists  of  small  round  or  oval  "lenticular" 
papules,  rose-pink  in  colour,  which  appear  up  to  the  number 
of  ten  or  twelve  on  the  back,  abdomen,  chest  and  shoulders. 
In  rare  cases  the  spots  may  be  very  numerous. 

The  spots  last  about  five  or  six  days  and  occur  in  succes- 
sive crops  ;  they  fade  on  pressure  throughout  their  existence 
except  when,  as  rarely  happens,  they  are  surmounted  by  a 
minute  vesicle. 

During  the  second  week  the  symptoms  are  all  intensified  ; 
the  patient  seems  too  exhausted  to  care  what  becomes  of 
him  ;  the  pulse  is  more  rapid  (110 — 120)  and  so  soft  as 
often  bo  become  dicrotic  ;  the  temperature  remains  about 
103°,  but  shows  a  distinct  morning  remission.  In  many 
cases  diarrhoea  is  persistent,  the  motions  being  very  offensive 
and  described  as  "  pea-soup,"  but  in  others  constipation 
supervenes,  A  low  muttering  delirium  is  common  at 
n'ght. 

About  the  end  of  the  third  week  the  sloughs  separate 
from  the  ulcerated  patches  in  the  intestine  and  more  or 
less  blood  may  appear  in  the  stools.  When  separation  of 
the  sloughs  is  complete,  the  temperature  falls  by  lysis, 
usually  returning  to  the  normal  about  the  end  of  the  fourth 
week.  During  the  fifth  and  sixth  weeks  relapses  may  occur  ; 
these  are  due  to  an  infection  of  hitherto  uninfected  Peyer's 
patches,  and  are  characterised  by  a  recurrence  of  symptoms 
and  signs,  which  do  not,  however,  last  for  more  than  a 
week  or  ten  days. 

Varieties.  In  addition  to  the  ordinary  form  described 
above  the  following  varieties  are  recognised  : — 

(i.)  Abortive.  Though  starting  with  what  appears  to  be 
the  ordinary  severity,  the  disease  may  terminate  by  crisis 
during  the  second  week. 

(ii.)  Ambulatory.     In   this    peculiarly  gra:V^   y^fiety  the 


SPECIFIC  INFECTIVE  DISEASES  17 

patient,  either  from  obstinacy  or  because  he  does  not 
feel  sufficiently  ill,  does  not  take  to  his  bed,  and  may  not 
infrequently  persist  in  his  ordinary  vocation  until  during 
the  third  week  perforation  of  an  ulcer  leads  to  general 
peritonitis  and  death.  Such  cases  are  often  first  diagnosed 
on  the  operating  table  or  at  the  autopsy. 

(iii.)  Enteric  Febricula.  An  extremely  mild  variety,  in 
which  the  symptoms  are  trivial  and  the  morning  tempera- 
ture often  normal. 

(iv.)  Ne2)hritic.  This  rare  form  starts  with  an  acute 
nephritis,  which  is  so  severe  as  to  mask  the  underlying 
enteric  fever. 

Although  the  main  varieties  of  enteric  fever  have  ^een 
briefly  outlined  above,  it  cannot  too  strongly  be  represented 
that  clinically  the  disease  rarely  conforms  strictly  to  tj^e, 
thus  : — 

The  course  may  be  prolonged  for  many  weeks. 
The  temperature  may  vary  within  wide  margins. 
The  eruption  may  not  appear  at  all  or  it  may  be  very 
profuse. 

Three  or  more  relapses  may  occur  for  no  very  apparent 
reason. 

Profuse  perspirations  may  suggest  septicaemia.  The  dis- 
proportionate severity  of  the  concomitant  bronchitis  may 
simulate  some  primary  pulmonary  affection.  An  inflamed 
throat  and  an  erythematous  eruption  may  for  the  moment 
reseinbk'  scarlet  fever. 

Complications,  (i.)  The  Alimentary  System.  It  is  here 
that  the  three  most  important  comphcations  are  met 
with  :— 

(a)  Hcemorrhage.  This  occurs  when  the  sloughs  sepa- 
rate, usually  at  the  end  of  the  third  week.  It  can  readily 
be  diagnosed  by  the  symptoms  of  collapse,  namely,  an 
abrupt  fall  in  the  temperatuic,  an  increased  rapidity  of 
the  pulse-rate,  great  restlessness  and  thirst,  combined 
eventually  with  the  passage  of  large  quantities  of  blood 
per  re(ttum. 

(/>)  Perforation.  This  occurs  at  the  same  period  as 
luemorrhage,  and  the  signs,  at  first,  arc  much  the  same, 
with  the  exception  that  there  is  no  loss  of  blood.  The 
M.D.  2 


18  MEDICAL   DIAGNOSIS 

diagnosis  of  perforation  may  be  extremely  difficult  in  the 
early  stages,  for  the  classical  signs  of  acute  peritonitis  are 
absent  for  a  considerable  time,  presumably  because  the 
exhausted  condition  of  the  patient  delays  the  ordinary 
reaction  of  the  peritoneum  to  the  irritating  intestinal 
contents.  In  conjunction  Avith  the  weak,  thready  pulse 
and  a  sudden  drop  in  temperature,  perhaps  to  95°, 
increasing  distension  of  the  abdomen  and  a  diminution 
in  the  area  of  liver  dulness  (due  to  free  gas  in  the  peri- 
toneum), as  estimated  by  percussion  in  the  right  mid- 
axillary  line,  will  justify  the  diagnosis  of  perforation, 
especially  if  a  blood  examination  shows  a  commencing 
leucocytosis. 

(c)  Meteorism.  Abnormal  abdominal  distension,  with 
which  may  usually  be  observed  the  presence  of  undigested 
curds  in  the  motions,  indicates  an  unsuitable  diet  and  is 
of  grave  import,  because  by  hampering  the  action  of  the 
diaphragm  and  compressing  the  thoracic  viscera  additional 
strain  is  thrown  upon  an  already  enfeebled  heart,  while 
perforation  of  an  ulcer  is  favoured  by  the  mechanical 
dilatation  of  the  gut. 

(ii.)  Cardiac.  Myocardial  degeneration,  with  its  resulting 
dilatation,  is  met  with  to  a  greater  or  less  extent  in  every 
case  of  enteric  fever  ;  endocarditis  leading  to  permanent 
valvular  disorganisation  may  occur  ;  pericarditis  can  be 
diagnosed  by  the  to-and-fro  rub  heard  on  auscultation. 

(iii.)  Thrombosis.  This  is  by  no  means  uncommon  :  the 
usual  site  is  the  left  femoral  vein,  but  cases  are  recorded  in 
which  the  inferior  vena  ca\^a  has  been  affected.  Thrombosis 
is  most  often  met  with  in  the  third  week,  but  may  occur  at 
any  time  during  convalescence. 

(iv.)  The  Resjnratory  System.  Pleurisy  and  pneumonia 
(lobar  and  lobular)  may  complicate  enteric  fever. 

(v.)  The  Nervous  System.  Neuritis  and  neuralgia,  e.g., 
the  so-called  "  Typhoid  Spifle,"  are  common  in  the  later 
stages,  while  acute  mania  may  be  met  with  at  the  height  of 
the  disease. 

(vi.)  Acute  nephritis  and  suppression  of  urine  sometimes 
occur  during  the  second  or  third  weeks,  but  are  more  often 
an  initial  manifestation. 


SPECIFIC  INFECTIVE  DISEASES  19 

(vii.)  The  Bony  System.  Cold  sub-periostial  abscesses  may 
occur  (the  typhoid  node)  ;  they  are  of  importance  because 
they  may  harbour  the  active  bacillus  for  many  years. 

Diagnosis,  (i.)  Getieml  Considerations.  Enteric  fever  is  a 
disease  of  children  and  young  adults  ;  it  is  most  frequent  in 
the  autumn,  and  is  liable  to  occur  in  epidemic  form,  though 
it  is  endemic  in  all  large  towns.  For  a  correct  diagnosis  we 
are  compelled  to  rely  on  the  grouping  together  of  several 
individual  symptoms  or  signs,  for,  with  the  exception  of 
Widal's  reaction,  no  single  one  can  be  regarded  as  pathogno- 
monic. The  most  important  guides  will  be  : — 
(a)  The  gradual  onset. 

(6)  The  step-ladder  type  of  temperature  during  the  first 
week  and  its  subsequent  remittent  character. 

(c)  The  combination  of  a  temperature  of  102*^  or  103° 
with  a  relatively  slow  pulse  (about  100)  (cf.  "  Tubercu- 
losis," p.  84). 

{d)  The  nature  of  the  pulse,  which  is  so  soft  as  often  to 
be  dicrotic. 

(e)  The  prominent  abdomen. 
(/)  The  splenic  enlargement. 
(g)  The  presence  or  history  of  diarrhoea. 
(h)  The  presence  of  bronchitis. 

{i)  The  characteristic  eruption  at  the  end  of  the  first 
week. 

Of  these  diagnostic  features  i)erhaps  the  most  valuable  are 
the  history  of  the  jnodc  of  onset,  the  appearance  of  the 
characteristic  rose  spots,  and  the  discovery  of  an  enlarged 
spleen. 

(ii.)  Special  Methods  of  Investigation,  (a)  The  Blood 
Count.  There  is  no  leueocytosis  in  enteric  fever — indeed, 
there  is  nearly  always  a  definite  leucopenia,  though  the  count 
may  show  a  relative  lymphocytosis.  A  leueocytosis  is  present 
in  every  other  exanthejuatous  fever  except  chicken-pox, 
measles,  and  German  measles. 

(b)  EhrlirJis  Diazo-reaction. — For  this  is  required  first  a 
•")  per  cent,  solution  of  sodium  nitrite  in  distilled  water, 
and  secondly  a  saturated  solution  of  sulphanilic  acid  in 
5  per  cent,  hydroclilorie  acid.  These  sohitioiis  must  be 
kept  separatti,  and  w  hen  the  reaction  is  to  be  performed  the 

2-2 


20  MEDICAL   DIAGNOSIS 

test  solution  is  made  by  adding  one  part  of  the  sodium 
nitrite  solution  to  one  hundred  parts  of  the  sulphanilic  acid 
solution.  If  some  of  this  be  mixed  with  an  equal  volume  of 
fresh  urine  and  an  excess  of  strong  ammonia  be  allowed  to 
run  gently  down  on  to  the  mixture,  a  deep  red  band  is 
formed  at  the  junction  of  the  ammonia  and  the  mixture  : 
if  shaken  a  rose-pink  foam  is  produced,  Avhile  a  green 
precipitate  is  formed  after  several  hours.  This  reaction  is 
practically  constant  in  enteric  fever  after  the  fourth  day, 
but  has  been  stated  to  occur  in  various  other  conditions 
such  as  pneumonia,  malaria,  and  miliary  tuberculosis.  Its 
value  is  therefore  largely  negativ^e — that  is  to  say,  its  per- 
sistent absence  excludes  the  diagnosis  of  typhoid. 

(c)  WidaVs  Reaction.  This  reaction  depends  on  the 
presence  of  agglutinins  in  the  blood  serum  of  persons  suffering 
from  enteric  fever.  The  serum  of  such  a  person  possesses  the 
power  of  causing  the  bacilli  in  an  emulsion  of  typhoid 
organisms  to  run  together  into  clumps.  The  reaction  is 
positive  or  negative,  according  to  the  dilution  of  the  serum 
which  is  necessary  to  cause  this  clumping  and  the  time  it 
takes  in  doing  so.  To  perform  the  test  there  are  required 
(a)  15  or  20  drops  of  the  patient's  blood,  and  (6)  an  emulsion 
made  from  an  eighteen  to  twenty-four  hours  old  culture  of 
virulent  typhoid  bacilli. 

The  patient's  finger  is  pricked  and  a  small  blood  capsule 
(Widal  tube)  filled  with  blood. 

The  emulsion  is  made  by  scraping  the  growth  off  the 
surface  of  the  culture  medium  with  a  platinum  loop  and 
mixing  it  thoroughly  with  a  few  drops  of  water  in  a  clean 
watch-glass. 

It  is  necessary  to  be  sure  that  the  emulsion  is  of  a  suitable 
consistence  and  also  that  the  organisms  are  active  and  not 
already  clumped.  Therefore  a  hanging-drop  preparation  of 
the  emulsion  is  first  examined  under  the  microscope  to  ensure 
that  each  field  contains  a  sufficiency  of  active  unclumped 
bacilli  but  is  not  too  thick  with  them.  If  it  is  too  thick  a 
little  more  water  must  be  added.  A  very  little  practice  will 
ensure  the  preparation  of  a  suitable  emulsion.  The  blood 
tube  is  now  centrifugalised  (if  the  serum  has  not  already 
separated  by  standing)  and  a  loopful  of  the  serum  placed  on 


SPECIFIC   INFECTIVE  DISEASES 


21 


a  clean  glass  slide.  Round  this  drop  of  serum,  but  not 
touching  it,  are  now  placed  four  loopfuls  (the  same  loop  must 
be  used)  of  sterile  broth.  These  are  now  mixed  thoroughl}^ 
together  and  the  result  is  a  serum  dilution  of  1  in  5. 

A  loopful  of  this  mixture  is  placed  on  another  slide  and 
mixed  in  the  same  way  with  four  more  loopfuls  of  broth  and 
a  serum  dilution  of  1  in  25  is  produced.  In  the  like  jnanner 
a  loopful  of  this  second  mixture  is  placed  on  a  third  slide  and 
a  serimi  dilution  of  1  in  50  is  effected  by  the  addition  of  one 
loopful    of    broth.      To    a 

loopful   of   each    of    these  ^--^"^^  ^^~^. 

dilutions  1  in  5,  1  in  25, 
and  1  in  50  is  added  a 
loopful  of  the  bacillary  / 
emulsion,  thus  producing 
final  serum  dilutions  of  1 
in  10,  1  in  50 ,  and  1  in 
100. 

Hanging-drop  prepara- 
tions of  these  three 
ultimate  mixtures  are  at 
once  made  and  examined 
microscopically. 

A  hanging-drop   is    not 
essential  —  ordinary    wet 
preparations  on  a  flat  slide 
with  a  cover-glass  dropped  on  to  the  fluid  are  quite  satis- 
factory ;   in  fact,  the  bacilli  are  easier  to  focus. 

If  the  patient  is  not  suffering  from  enteric  fever,  the 
bacilli  will  continue  to  be  evenly  diffused  throughout  the 
fllni  and  to  be  actively  motile. 

If  the  patient  is  suffering  from  enteric  fever,  the  move- 
ments of  the  bacilli  will  be  seen  gradually  to  cease  and  they 
will  become  aggregated  together  into  little  clumps. 

The  reaction  may  be  considered  positive  if  there  is  aggluti- 
nation in  thirty  minutes  with  a  dilution  of  1  in  50. 

The  reason  for  advising  the  use  of  thnn*  dilutions  is  as 
follows  :■ — 

If  agglutination  occurs  at  all  quickly  with  a  dilution  of 
1  in  100,  the  diagnosis  is  very  positive. 


Fiii.  7. — Widal  J;  lowing  Agglu 

tination  of  ijauum-  i^-phosus  (un- 
stained) by  the  blood  serum  of  a 
patient  suffering  from  Enteric  Fever. 
Magnification  x  1000. 


22  MEDICAL  DIAGNOSIS 

If  no  agglutination  occurs  with  a  dilution  of  1  in  10,  a 
negative  diagnosis  is  probable,  but  since  some  healthy 
serums  show  a  certain  amount  of  agglutination  of  typhoid 
bacilli  in  this  small  dilution,  it  is  not  justifiable  to  give  a 
positive  diagnosis  on  this  alone. 

It  is  not  essential  to  use  a  live  culture  for  the  performance 
of  the  Widal  reaction.  Dead  cultures  are  also  agglutinated 
by  the  serum  of  enteric  fever  patients. 

Dead  cultures,  if  kept  long  in  emulsion  form,  tend  to 
become  clumped  spontaneously,  and  this  may  spoil  the  experi- 
ment. At  the  same  time  the  use  of  a  standard  emulsion  of 
dead  bacilli  is  very  much  more  within  the  scope  of  the  general 
practitioner,  and  affords  excellent  results  promled  that  the 
uniformity  of  suspension  is  tested  before  each  experiment. 

The  dead  bacilli  may  be  used  exactly  as  described  above, 
or,  if  preferred,  the  macroscopic  method  may  be  employed. 

For  this  purpose  a  rather  wide  bore  "  capillary  pipette  " 
about  6  inches  long  is  used.  A  mark  is  made  on  this  about 
1^  inches  from  the  end.  The  tube  is  filled  with  diluted  serum 
to  the  mark  ;  a  bubble  of  air  is  next  allowed  to  enter  the 
pipette,  which  is  then  filled  to  the  mark  with  the  bacillary 
emulsion.  The  emulsion  and  serum  are  well  mixed  by  blow- 
ing them  out  several  times  into  a  watch-glass  and  sucking 
them  back  into  the  pipette.  Finally,  the  bottom  of  the 
pipette  is  sealed  off  and  the  whole  thing  is  left  for  twenty- 
four  hours  in  an  upright  position.  A  positive  reaction  is 
shown  by  the  presence  of  a,  floccident  granular  deposit  at  the 
bottom  of  the  tube,  the  supernatant  fluid  being  clear. 

A  control  should  always  be  employed.  This  shows  a 
uniform  even  layer  of  bacilli  at  the  bottom  of  the  tube,  an 
appearance  which  is,  of  course,  also  given  in  a  negative 
reaction. 

The  macroscopic  reaction  can  equally  well  be  employed 
with  live  bacilli,  and  the  result  is  even  easier  to  read,  since  in 
a  negative  reaction  the  whole  tube  remains  turbid,  while  in 
a  positive  reaction  the  flocculent  masses  of  agglutinated 
organisms  settle  to  the  bottom  of  the  tube  just  as  in  the 
case  of  the  dead  bacilli.  With  the  exception  of  cultivation 
of  the  Bacillus  typhosus  from  the  patient's  blood,  a  positive 
Widal  reaction  is  the   most  certain  means  at  our  disposal 


SPECrFIC  INFECTIVE  DISEASES  23 

for  the  diagnosis  of  enteric  fever  ;  but  it  is  most  necessary  to 
remember  that  the  reaction  is  not  commonly  present  till 
the  eighth  day  of  the  disease,  and  also  that  patients  who 
have  once  had  enteric  fever  may  give  the  reaction  for 
several  years. 

(d)  The  Recovery  of  the  Specific  Organisms  from  the  Blood, 
Urine  and  Fceces.  It  is  sometimes  of  importance,  especially 
in  military  encampments  and  in  the  tropics,  to  make  a  posi- 
tive diagnosis  before  the  eighth  day,  and  it  has  been  found 
possible  to  grow  the  bacillus  from  the  blood  of  infected 
patients  as  early  as  the  third  or  fourth  day.  This  means  of 
diagnosis  is  simple  and  very  accurate  {vide  p.  157)  ;  it  should 
be  attempted  in  every  case,  as  a  positive  diagnosis  can  be 
made  earlier  than  in  any  other  way.  The  bacilli  may 
usually  be  found  in  the  urine  and  faeces,  though  their  iden- 
tification from  the  latter  material  is  comphcated  by  the 
multitude  of  similar  organisms  which  are  normally  present. 

Differential  Diagnosis.  Unless  blood  cultivation  is  per- 
formed, it  may  be  extremely  difficult  to  distinguish  enteric 
fever  from  the  following  conditions  until  the  eighth  day, 
when  Widal's  reaction  can  be  employed : — 

(i.)  Septiccemia  and  Ulcerative  Endocarditis.  A  primary 
septic  focus  may  be  found  or  obviously  active  endocarditis 
may  be  present ;  frequent  perspirations  and  rigors,  or  the 
occurrence  of  infarction  as  well  as  a  prominent  leucocytosis 
may  help  in  the  diagnosis,  while  the  temperature  is  apt  to 
show  greater  variations  than  is  the  case  in  enteric  fever. 

(ii.)  Miliary  Tuberculosis.  The  patient  may  present  some 
obvious  tuberculous  lesion,  the  temperature  may  well  be 
intermittent  or  even  of  the  inverse  typo,  while  splenic 
enlargement  is  unusual  and  the  pulse-rate  is  apt  to  be  rather 
higher  than  in  enteric  fever. 

(iii.)  A  Tuberculous  Storm  in  the  Mesenteric  Glands.  This 
condition  may  so  exactly  simulate  enteric  fever  that  diag- 
nosis is  impossible  until  a  negative  Widal  has  been  obtained, 
though  a  wide  variation  in  the  opsonic  index  to  tubercle 
when  the  temperature  is  at  its  highest  and  lowest  respectively 
is  likely  to  be  found,  while  if  the  patient  be  under  six  years 
of  age  von  Pirquet's  tuberculo-cutaneous  reaction  is  of 
value. 


24  MEDICAL   DIAGNOSIS 

(iv'.)  Appendicitis.  The  sudden  onset,  the  locahsing 
symptoms,  the  possible  history  of  prev^ious  attacks,  the 
increasing  pulse-rate,  the  frequency  of  vomiting,  and  a 
leucocytosis  will  usually  lead  to  a  correct  diagnosis. 

(v.)  Lobar  Pneumonia.  The  rapidity  of  the  respirations 
and  the  high  leucocyte  count,  as  well  as  the  aspect  of  the 
patient  and  the  possibility  of  herpes  labialis,  will  usually 
prevent  a  mistake  being  made,  but  it  must  be  remembered 
that  lobar  pneumonia  and  enteric  fever  may  co-exist  and 
also  that  in  psittacosis  (a  disease  conveyed  to  man  by  infected 
parrots)  a  lobar  pneumonia  is  present  at  the  same  time  as 
a  chronic  enteritis,  and  further,  that  in  this  disease  the 
patient's  serum  will  agglutinate  the  Bacillus  typhosus.  The 
diagnosis  here  must  depend  on  the  proximity  of  a  sick 
parrot. 

(vi.)  Malaria  does  not  give  a  true  Diazo -reaction  and  the 
Plasmodium  can  be  found  in  blood-films  from  the  patient, 
otherwise  some  remittent  forms  of  malaria  may  closely 
resemble  enteric  fever. 

(vii.)  Para-typhoid  Infection.  The  condition  produced  by 
this  bacillus  may  be  absolutely  indistinguishable  from  enteric 
fever  until  the  agglutination  test  shows  that  the  patient's 
serum  will  clump  one  of  the  group  of  para-typhoid  bacilli 
and  not  the  Bacillus  typhosus. 

(viii.)  hifluenza.  The  abdominal  type  of  influenza  maj^ 
easily  be  mistaken  for  enteric  fever,  but  as  a  rule  the 
sudden  onset,  the  rapid  rise  of  temperature,  the  absence 
of  splenic  enlargement,  as  well  as  the  more  pronounced 
character  of  the  abdominal  symptoms,  should  prevent  such 
a  mistake. 

From  the  foregoing  considerations  the  importance  of 
Widal's  reaction  will  be  apparent  ;  if  properly  performed 
the  margin  of  error  is  probably  less  than  three  per  cent. 

VII.  ER.YSIPELAS. 

Definition.  A  specific  infective  disease  characterised  by 
a  spreading  dermatitis  and  caused  by  the  Streptococcus 
pyogenes. 

Incubation  Period.     From  two  to  seven  days. 


SPECIFIC   INFECTIVE   DISEASES 


25 


Course.  The  onset  is  abrupt,  with  rigors,  headaches, 
and  vomiting,  while  the  temperature  rises  to  103'^  or  104°. 

The  inflammation,  except  in  traumatic  cases,  usually 
starts  at  a  muco-cutaneous  junction,  and  spreads  along 
the  skin  rather  than  the  mucous  membrane,  though  both 
may  be  involved.  The  affected  skin  is  red,  swollen  and 
painful,  while  bullae  frequently  appear  on  its  surface.  The 
inflamed  area  is  surrounded  by  a  sharply-defined,  bright- 
red  raised  margin,  which  tends  to  spread  by  the  lym- 
phatics, either  rapidly  or  slowly,  so  as  to  include  an  increas- 
ing area  of  hitherto  un- 
infected skin.  While  the 
infection  is  extending  peri 
pheraUy  the  parts  first 
involved  may  be  recover- 
ing. Delirium  is  frequent, 
Avhile  in  elderly  or  debili 
tated  persons  a  condition 
of  profound  toxaemic  ex 
haustion  may  rapidly 
supervene.  The  termina- 
tion is  usually  by  crisis  on 
the  seventh  to  tenth  day. 

Varieties,    (a)    An    acute 
form,  as  described  above. 

(6)  A  chronic  form,  or  erysipelas  migrans,  in  which  the 
constitutional  disturbance  is  slight  and  the  inflammation 
slowly  wanders  from  one  part  of  the  body  to  another. 

Complications.  Complications  are  most  likely  to  be  seen 
when  the  infection  attacks  the  mucous  membrane  of  the 
mouth  or  fauces. 

(Edema  of  the  glottis  may  then  occur,  producing  respira- 
tory obstruction,  as  shown  by  laryngeal  stridor  and  even 
a.sphyxiation. 

Broncho-pneumonia  may  develop  from  the  inhalation  of 
septic  particles. 

(hllulitis,  with  pus  formation,  is  yet  another  complication, 
and  is  of  particular  gravity  should  it  affect  the  fauces, 
])harynx  or  orbit,  in  which  latter  case  a  spread  of  infection 
to  the  cerebral  meninges  has  been  recorded. 


Fig.   8  — Film   pitparation   of   Strepto- 
coccus Pyogenes.    Magnification  ;<  1000. 


26 


MEDICAL  DIAGNOSIS 


Erysipelas  of  the  scalp  is  commonly  followed  by  baldness. 

Diagnosis.  There  is  no  disease  except  erysipelas  which 
presents  the  above-mentioned  features.  Syphilitics  and 
women  during  the  puerperium  seem  peculiarly  liable  to 
this  infection,  while  certain  other  individuals  may  suffer 
repeated  attacks  for  no  apparent  reason. 

The  complication    of    pus  formation  can  be  diagnosed 


i 

106° 
105' 
10*° 
103' 
lOZ' 
101° 
100° 
99° 
98° 
97° 
96° 

M    E 

M   E 

M   E 

M  e 

M    E 

M  E 

M  E 

M  E 

ME 

M   E 

M  E 

M  E 

M  E 

a: 

■■    / 

\^ 

■\ 

A 

\ 

:\ 

■\ 

fl 

'■r 

f  ■■ 

\ 

v" 

"n 

j 

A 

v^ 

■ 

■ 

I:, 

' 

• 

V 

V 

.\ 

_^. 

.-m 

.-. 

_i. 

"I" 

.^. 

\ 

-•- 

•-- 

••" 

.^. 

"T" 

T 

: 

N,, 

r- 

0. 

130 

no 
no 

100 
90 
so 

70 

so 

A 

'^/\ 

': 

A 

Y 

\ 

r 

-<., 

/ 

y 

V- 

s/ 

\y 

V 

s^ 

■^- 

1 

1 

1 

S5 

45 
35 
25 

:■ 

/^ 

A 

•r' 

V^ 

^'^ 

v^' 

: 

^^ 

Fig.  9.— Chart  from  a  case  of  Erysipelas. 

by  the  brawny,  boggy,  or  oedematous  appearance  of  the 
affected  parts.  Occasionally  the  inflammation  round  a 
vaccination  pustule  may  at  first  suggest  erysipelas  ;  the 
characteristic  edge  is,  however,  absent,  and  the  fact  that 
vaccination  had  been  performed  would  suggest  that  true 
erysipelas  was  not  present.  Of  course,  erysipelas  may 
follow  vaccination,  so  a  guarded  prognosis  is  necessary 
for  a  few   days.     The   early  stages   of  malignant  pustule 


SPECIFIC    INFECTIVE  DISEASES  27 

may  simulate  erysipelas,  but  the  central  black  scar 
with  its  ring  of  secondary  vesicles  would  soon  settle  the 
diagnosis. 

VIII.  GERMAN  MEASLES. 

Definition.  A  specific  infective  disease  of  unknown 
causation,  characterised  by  a  red  rash  and  glandular  enlarge- 
ment, most  commonly  met  with  in  children. 

Incubation  Period.  Twelve  to  twenty-one  days,  usually 
eighteen. 

Course.  Constitutional  disturbance  is  slight  or  absent. 
There  may  be  trifling  malaise  and  headache  or  mild  catarrhal 
symptoms  and  sore  throat.  The  temperature,  though 
often  normal,  will  sometimes  rise  to  100°  for  forty-eight 
hours. 

In  twenty-four  hours  the  rash  appears,  and  this  is  often 
the  first  sign  of  the  infection.  The  rash  is  composed,  of 
rather  bright-red  papules,  which  usually  appear  first  on  the 
face,  and  particularly  about  the  mouth  and  nose.  Within 
a  very  few  hours  the  trunk  and  arms  are  covered  ;  the  legs 
are  usually  involved  after  a  short  interval.  The  papules 
tend  to  run  together,  but  do  not  commonly  cause  such  a 
blotchy  appearance  as  in  true  measles. 

Within  twelve  hours  from  its  appearance  the  rash  begins 
to  fade  and  is  completely  gone  in  three  days  ;  a  fine  branny 
desquamation  usually  follows.     Itching  is  absent  or  shght. 

At  the  same  time  as  the  appearance  of  the  rash  the  fauces 
will  be  found  to  be  infected,  and  not  infrequently  macular 
spots  may  be  found  in  the  throat.  There  is  often  a  shght 
generalised  glandular  enlargement.  This  is  most  apparent 
in  the  posterior  triangles  of  the  neck. 

Complications  are  practically  unknown. 

Differential  Diagnosis,     (i.)  From  Measles  [vide  p.  41). 

(ii.)   From  Scarlet  Fever  (r^ide  p.  64). 

(iii.)  From  Food  Poisoning.  Shell-fish,  strawberries,  etc., 
may  in  susceptible  people  produce  a  rash  which  resembles 
that  of  Cerman  measles.  Such  rashes  usually  cause  con- 
siderable irritation.  The  diagnosis  must  depend  on  the 
history    of    similar    previous    attacks,    on    the    individual's 


28  MEDICAL   DIAGNOSIS 

known  liability  to  such  occurrences,  and  on  the  absence  of 
glandular  enlargements. 

True  ptomaine  poisoning  is  accompanied  by  such  severe 
constitutional  disturbance,  e.g.,  diarrhoea  and  vomiting, 
that  mistake  is  unlikely. 

(iv.)  From  Drug  Rashes.  Copaiba,  bromide,  iodides, 
belladonna,  salicylates,  etc.,  may  sometimes  produce  a 
rash  like  that  of  German  measles.  They  are,  however, 
usually  more  or  less  localised  in  their  distribution,  and 
inquiry  will  reveal  the  fact  that  some  such  drug  has 
recently  been  taken,  while  in  the  case  of  belladonna, 
iodides,  or  salicylic  acid  the  dilated  pupils,  profuse  coryza, 
and  buzzing  in  the  ears  respectively  will  help  to  clinch  the 
diagnosis. 

After  administration  of  an  enema  a  measly  or  scarlatini- 
form  rash  will  sometimes  occur  ;  it  appears  first  on  the 
thighs  and  abdomen,  and  is  often  localised  to  these  parts. 

IX.  HYDROPHOBIA. 

Definition.  A  specific  infective  disease  conveyed  to  man 
by  the  bites  of  rabid  wolves,  cats,  and  dogs.  The  causative 
organism  has  not  yet  been  demonstrated. 

Incubation  Period.  From  three  weeks  to  two  yea,rs. 
Usually  from  six  to  eight  weeks. 

Course.  The  original  bite  is  usually  complete^  healed. 
The  patient  becomes  restless,  depressed,  irritable,  and  has 
a  well-marked  sense  of  impending  disaster  ;  at  the  same 
time  there  is  generally  a  sense  of  discomfort,  tingling,  and 
even  pain  in  the  scar  of  the  bite.  In  a  few  days  there  is  a 
choking  feeling  in  the  throat,  a  huskiness  in  the  voice,  and 
a  difficulty  in  swallowing.  The  next  manifestations  of  the 
disease  are  spasms  of  the  muscles  of  deglutition  and  respira- 
tion, which  are  excited  by  the  attempt  to  drink  or  swallow, 
and  later  by  the  most  trivial  causes,  such  as  a  breath  of  air 
or  a  slight  noise. 

The  spasmodic  convulsions  soon  spread  to  other  parts 
of  the  body,  and  at  the  same  time  there  is  intense  cutaneous 
hypersesthesia.  The  expression  becomes  one  of  acute 
anxiety  and  terror,  the  temperature  is  raised,  delirium  and 


SPECIFIC   INFECTIVE   DISEASES  29 

mania  ensue,  and  the  patient  dies  in  from  two  to  three  days 
from  syncope  or  asphyxia. 

Diagnosis.  AV'hen  the  characteristic  symptoms  of  the 
disease  have  appeared  the  diagnosis  is  simple  ;  the  important 
point  is  to  determine  wliether  or  no  an  animal  that  has 
bitten  people  is  rabid.  The  suspected  am'mal  should  be 
isolated  for  observation,  when,  if  rabid,  it  will  die  in  five 
days. 

If  through  over-zeal  the  animal  has  been  destroyed,  a 
portion  of  its  medulla  oblongata  should  be  emulsified  and 
injected  into  the  dura  mater  of  a  rabbit.  The  rabbit  will 
die  of  rabies  in  from  fifteen  to  twenty-five  days. 

It  has  been  stated  by  Negri  that  small  irregular-shaped 
protozoa  can  be  demonstrated  in  the  brain,  pons,  spinal 
cord,  and  cornu  ammonis  of  rabid  animals,  and  that  by 
this  means  a  reliable  diagnosis  can  be  made  within  twenty- 
four  hours.  ^ 

Hydrophobia  must  not  be  mistaken  for  : — 

(i).  Lyssophobia.  This  is  a  hysterical  manifestation 
occurring  in  nervous  persons  who  have  been  bitten  by  a 
dog. 

The  premonitory  symptoms  of  hydrophobia  are  accu- 
rately simulated,  but  there  is  no  pyrexia,  and  the  symptoms 
never  go  further  than  a  professed  inability  to  swallow. 

This  condition  may  persist  much  longer  than  would 
true  rabies,  and  is  amenable  to  treatment  in  the  nature  of 
electricity  and  moral  persuasion. 

(ii.)  Tetanus.  In  hydrophobia  there  is  no  tonic  rigidity, 
opisthotonos,  or  trismus.  In  tetanus  there  is  no  mental 
disorder,  though  should  tetanus  follow  a  wound  on  the  head 
there  will  be  spasms  of  the  pharynx  ;  there  will,  however, 
also  be  facial  paralysis,  which  does  not  occur  in  hydrophobia. 
Lastly,  it  is  very  rare  for  tetanus  to  follow  the  bite  of  a 
dog. 

X.  GLANDERS. 

Definition.  A  specific  infective  disease  of  horses,  con- 
veyed by  them  to  man,  due  to  the  Bacillus  mallei,  and 
characterised  by   the  formation  of  iiHiltiple  granulomatous 


30  MEDICAL   DIAGNOSIS 

abscesses  in  the  nose  or  along  the  course  of  the  cutaneous 
lymphatics. 

Varieties,  (i.)  Glanders,  which  is  primarily  an  infection  of 
the  nasal  mucosa. 

(ii.)  Farcy,  which  is  primarily  a  cutaneous  or  lymphatic 
infection. 

Either  variety  in  the  acute  form  tends  to  become  compli- 
cated by  the  other,  whilst  chronic  forms  of  both  glanders  and 
farcy  are  described. 

Incubation  Period.  Up  to  four  days.  In  rare  cases  it 
may  be  much  longer. 

Course,  (i.)  Acute  Glanders.  The  invasion  is  sudden, 
with  headache,  rigors,  and  prostration  ;  joint  and  muscle 
pains  are  common. 

About  the  second  day  the  nose  becomes  swollen  and  pain- 
ful, and  shortly  afterwards  there  is  a  profuse  blood-stained 
nasal  discharge  ;  at  the  same  time  the  cervical  lymph  glands 
are  much  enlarged.  Towards  the  end  of  the  week  an  erup- 
tion appears  about  the  face,  trunk  and  joints  ;  this,  at  first 
papular,  rapidly  pustulates,  and  may  closely  resemble 
small-pox.  Death  ensues  during  the  second  week,  and  is 
often  preceded  by  a  sub -acute  pneumonia. 

Chronic  Glanders.  The  constitutional  disturbance  is 
much  less  acute  ;  there  is  a  chronic  nasal  discharge  and 
ulceration  of  the  nose,  but  a  skin  rash  is  uncommon. 

The  deration  may  be  several  months  and  recovery  may 
take  place. 

(ii.)  Acute  Farcy.  The  nose  is  not  affected  and  the  skin 
eruption  is  absent.  Instead  there  is  an  intense  lymphangitis, 
with  nodular  masses  of  granulation  tissue  distributed  along 
the  course  of  the  lymphatics.  These  nodules  eventually 
suppurate.  Joint  pains  are  common,  and  abscesses  may 
form  in  the  muscles. 

It  will  be  seen  that  the  disease  bears  a  striking  resemblance 
to  an  acute  pyaemia. 

Death  usually  occurs  at  the  end  of  the  second  week. 

Chronic  Farcy.  In  this  variety  there  are  localised 
abscesses  which  are  situated  usually  in  the  extremities  and 
bear  no  definite  relation  to  the  lymphatics. 

True  pyaemia,  or  even  acute  glanders,  may  supervene  ; 


SPECIFIC   INFECTIVE   DISEASES 


31 


otherwise  the   disease  drags  out  a  protracted  course  for 
months  or  years  and  may  ultimately  end  in  recovery. 

Diagnosis.  In  view  of  the  fact  that  primarily  the  disease 
is  one  of  horses,  the  history  of  employment  and  exposure  to 
infection  is  of  paramount  importance. 

The  absolute  diagnosis  depends  on  the  recovery  of  the 
specific  bacillus  from  the  nasal  discharge  or  from  one  of  the 
lesions. 

The  glanders  bacillus  is  a  small,  straight  or  slightly-curved 
rod  with  rounded  ends.  It  is  rather  thicker  than  a  tubercle 
bacillus,  but  about  the 
same  length.  The  pro- 
toplasm is  often  very 
granular.  The  shape  and 
size  of  the  organisms  are 
not  constant.  The  bacillus 
is  non-motile,  and  does 
not  form  spores.  It  stains 
readily  with  ordinary 
dilute  basic  stains,  and 
is  decolourised  by  the 
method  of  Gram. 

In  films  of  pus  from 
a  patient  suffering  from 
glanders  the  organisms  are 
nearly  all  extra-cellular. 

The  best  culture  medium  for  the  glanders  bacillus  is  blood 
serum  on  which  medium  round,  rather  transj^arent,  drop- 
like colonies  become  visible  in  twenty-four  hours. 

It  is  in  chronic  cases  that  the  greatest  diagnostic  difficulty 
will  be  experienced.  Even  though  the  bacillus  itself  may 
not  be  visible  either  on  cultivation  or  in  film  preparations, 
nevertheless  films  made  from  the  pus  of  a  glandered  subject 
will  often  show  a  peculiar  granular  appearance,  due  to 
disintegration  of  nuclei,  such  as  is  rarely  met  with  in  other 
conditions. 

To  establish  the  diagnosis,  however,  it  is  best  to  inject  a 
small  quantity  of  the  suspected  material  into  the  peritoneum 
of  a  male  guinea-pig.  At  the  end  of  two  days,  if  the  case 
be  one  of  glanders,  the  testicles  of  the  guinea-pig  will  be 


Fig.  10      Bacillus  Mallei   from  48  hours 
culture  on  potato.     Magnificatioa  /.  1000. 


32  MEDICAL   DIAGNOSIS 

distinctly  swollen.  This  swelling  increases,  suppuration 
ensues,  and  in  three  weeks  the  animal  dies  with  generalised 
glanderous  nodules  in  the  viscera. 

The  following  diseases  may  be  confounded  with  glanders 
before  the  inoculation  of  the  guinea-pig  has  verified  the 
diagnosis  : — 

(i.)  S7naU-pox.  The  swelling  of  the  nose  and  lymph 
glands  and  the  nasal  discharge  in  glanders,  as  well  as  the 
greater  rapidity  of  pustulation,  should  prevent  this  mistake. 

(ii.)  Sporo-trichosis  may  resemble  farcy,  but  the  extreme 
chronicity  of  this  disease,  with  little  or  no  impairment  of 
general  health  and  the  tendency  of  the  nodules  to  remain 
unbroken  for  a  long  period,  as  well  as  the  presence  of  a 
streptothrix  organism,  will  assist  in  the  diagnosis. 

(iii.)  Chronic  Coryza.  This  may  exactly  simulate  a  mild 
case  of  chronic  glanders.  Examination  of  the  nose  will 
usually  reveal  multiple  small  ulcers,  and  in  any  doubtful 
case  injection  of  a  guinea-pig  must  at  once  be  undertaken. 

To  diagnose  glanders  in  horses  mallein,  prepared  and  used 
in  the  same  way  as  Koch's  old  tuberculin  {q.v.),  is  highly 
recommended. 

XI.  GONORRH(EA. 

Definition.  A  specific  infective  disease  caused  by  the 
gonococcus  and  characterised  by  local  inflammation  at  the 
site  of  infection  and  sometimes  accompanied  by  various 
metastatic  inflammatory  phenomena. 

Incubation  Period.  Two  to  nine  days.  The  incubation 
period  is  usually  shorter  in  a  second  or  third  attack,  but  with 
the  first  infection  symptoms  usually  become  manifest  on  the 
fourth  or  filth  day. 

Manifestations  and  Diagnosis.  The  purulent  urethritis, 
with  the  more  usual  complications  of  epidydimitis,  orchitis, 
prostatic  abscess,  cystitis,  and  inguinal  bubo,  are  appro- 
priately described  in  text-books  on  surgery.  Similarly,  an 
account  of  the  pelvic  and  peritoneal  complications  of 
gonorrhoea  in  the  female  will  be  found  in  manuals  on  Diseases 
of  Women. 

We  are  here  concerned  only  with  those  manifestations  of 


SPECIFIC   INFECTIVE   DISEASES  33 

gonorrhoea  which  indicate  that  the  organisms  have  entered 
the  blood-stream  and  produced  a  condition  of  septicaemia. 

(i.)  Arthritis.  This  usually  occurs  during  an  acute 
attack,  though  it  is  more  likely  to  happen  with  a  subsequent 
attack  than  at  the  first  infection.  Nevertheless,  it  may 
complicate  ophthalmia  neonatorum,  or  it  may  only  become 
evident  when  the  urethritis  has  quieted  down  into  a  chronic 
gleet.  An}^  one  of  the  joints  in  the  bodj-  may  be  affected, 
but  it  is  noteworthy  that  the  temporo-mandibular,  sterno- 
clavicular, and  spinal  articulations  are  frequently  involved. 
It  is  extremely  rare  for  these  joints  to  be  affected  by 
rheumatism.  The  inflammation  may  be  mostly  j^eri- 
articular,  or  it  may  be  a  practically  painless  hydrarthrosis. 
Suppuration  may  occur,  but  is  uncommon.  Whatever  the 
manifestation  of  the  disease,  its  extreme  chronicity  and 
resistance  to  treatment  are  important  diagnostic  points. 

Any  inflammation  attacking  tendons  and  tendon  sheaths 
and  bursse  may  well  be  gonorrhoeal  ;  flat-foot  is  common, 
and  a  local  periosteal  thickening  with  exostosis  on  the 
under  surface  of  the  os  calcis  may  give  rise  to  great  pain  and 
lameness. 

The  great  difficulty  in  diagnosis  is  to  distinguish  gonor- 
rhoeal arthritis  from  acute  or  sub -acute  rheumatism.  The 
diagnosis  will  rest  on  the  following  points  : — 

(a)  The  history  of  an  active  urethritis,  or  even  of  a 

chronic  gleet  (in  the  case  of  women  the  vaginal  discharge 

should  be  examined  for  gonococci). 

(6)  The  sudden   appearance    of    pain  and  swelling   in 

several  joints,  with  the  absence  of  that  flitting  from  joint 

to  joint  which  is  so  characteristic  of  acute  rheumatism. 

(c)  A  constitutional  disturbance  more  slight  and  a 
less  high  temperature  than  the  severity  of  the  joint  })ains 
might  appear  to  warrant. 

(d)  The  absence  of  profuse  perspirations,  caidiac 
lesions,  and  rheumatic  nodules. 

(e)  And,  possibly  most  important  of  all,  the  fact  that 
the  symptoms  are  not  ameliorated  by  the  exliibition  of 
salicylates. 

(ii.)  C())i}i(nrflrilis  and  Iritis.     A  piiruk'nt  infhimmation 
of  the  conjunctiva  is  commonly  conveyed  by  direct  infection 
M.D.  3 


34  MEDICAL   DIAGNOSIS 

of  gonorrhoeal  pus  on  fingers,  towels,  etc.,  but  it  may  also 
be  a  metastatic  phenomenon  in  the  course  of  a  gonococcal 
septicsemia. 

(iii.)  Endocarditis  and  Pericarditis  will  give  the  usual 
signs  of  such  conditions. 

(iv.)  Neuritis,  k  symmetrical  polyneuritis  may  some- 
times occur  with  the  symptoms  of  pain,  numbness,  and 
tingling  followed  by  paralysis.  Though  the  neuritis  is 
often  localised,  it  may  give  rise  to  a  rapidly  ascending 
paralysis,  until  death  ensues,  with  the  involvement  of  the 
phrenic  nerves,  in  a  few  days  from  the  onset. 

Bacteriology.  The  gono- 
coccus  is  a  small  coccus 
usually  found  in  pairs 
(diplococcus).  The 
adjacent  surfaces  of  the 
cocci  are  often  indented, 
thus  giving  rise  to  an 
appearance  as  of  two  beans 
placed  side  by  side.  It 
stains  well  with  all  basic 
aniline  dyes,  but  is  de- 
colourised by  Gram's 
method.  It  is  abundant 
Fig.  il.--Gonococ.cu.s  in  Uretlirai  pus.  -^^  ^j^^  urethral  discharge. 
Magnification  , :  1000.  .  ="   ' 

the   organisms   being  seen 

for  the  most  part  within  the  leucocytes.  It  can  often  be 
demonstrated  in  the  fluid  of  a  gonorrhoeal  joint,  and  in  severe 
cases  of  gonorrhoeal  septicaemia  may  be  grown  from  the 
blood  of  the  patient. 

The  organism  is  best  cultivated  on  a  medium  of  inspissated 
human  or  rabbit's  blood  serum,  though  an  ordinary  agar 
tube  freshly  smeared  with  human  blood  will  answer  the 
purpose.  The  culture  medium  should  be  lightly  rubbed 
v/ith  a  platinum  loop  containing  the  suspected  pus,  or  in 
the  case  of  effusion  from  a  joint  with  a  portion  of  the  centri- 
fugalised  deposit.  The  tube  should  then  be  incubated  at 
the  body  temperature,  when  in  from  twenty-four  to  forty- 
eight  hours  small,  roughly  circular,  opaque  white  colonies 
of  gonococci  will  be  apparent. 


SPECIFIC   INFECTIVE  DISEASES  35 

It  is  a  noteworthy  point  that  in  the  a<^liilt  female  the 
gonococcus  does  not  ordinarily  affect  the  vaginal  mucous 
membrane  ;  it  chooses  rather  the  urethra  or  the  cervix 
uteri.  This  is  not  so  in  the  case  of  children,  and  a  large 
proportion  of  the  cases  of  vulvo-vaginitis  in  young  girls  is 
due  to  the  gonococcus. 

XII.  INFLUENZA. 

Definition.  A  specific  infective  disease  of  an  extremely 
infectious  nature  occurring  at  irregular  intervals  in  wide- 
spread epidemics,  and  in  the  meanwhile  apparently  remain- 
ing endemic  throughout  the  ci%alised  world. 

Bacteriology.  Influenza  is  caused  by  a  specific  micro- 
organism, the  Bacillus  influenza^  of  Pfeiffer.  This  is  a 
minute  rod-shaped  bacillus,  which  stains  feeblj'  with  the 
basic  aniline  dyes  and  is  best  demonstrated  by  staining 
with  10  per  cent,  carbol-fuchsin.  It  is  decolourised  by  Gram's 
method.  It  is  somewhat  difficult  to  cultivate  except  in  the 
presence  of  haemoglobin.  Fresh  blood  agar  is  therefore  the 
best  culture  medium. 

Clinically  indistinguishable  conditions  may  be  caused  by 
the  Micrococcus  catarrhalis,  the  Pneumococcus,  etc.,  or  a 
combination  of  such  organisms. 

Incubation  Period.     Usually  three  or  four  days. 

Course  and  Varieties.  The  manifestations  of  influenza  are 
so  varied  that  it  is  convenient  clinically  to  describe  the 
disease  as  occurring  in  the  following  five  varieties.  It  has 
been  noticed  that  one  or  other  form  is  likely  to  predominate 
in  any  given  epidemic  : — 

(i.)  Respiratory.  This  is  certainly  the  most  common 
form  of  influenza.  The  onset  is  sudden,  with  severe  pain 
in  the  head,  particidarly  behind  the  eyes,  in  the  back 
and  in  the  limbs.  Vomiting  may  occur  and  the  temperature 
ri.ses  to  102°  or  10.3°.  The  pulse  is  full  and  bounding  but 
not  very  ra})i(l,  usually  from  00  to  100  per  minute.  TIktc 
is  coryza.  Avith  catarrii  of  the  respiratory  tract,  bronchitis, 
cough,  and  not  infre(piently  a  green  nummular  expecto- 
ration. A  sore  throat  with  injection  and  inllaniinat ion  of 
tlie  faucial  pillars  is  often  found. 

3—2 


36 


MEDICAL   DIAGNOSIS 


(iii.)   The  Cerebral  form. 


There  is  a  tendency  for  the  symptoms  to  abate  in  the 
morning  and  to  recur  each  evening  for  several  days. 
The  prostration  of  the  patient  is  extreme, 
(ii.)  Gastro-intestinal.  Severe  abdominal  pain  with  vomit- 
ing and  diarrhoea  may  take  the  place  of  the  respiratory 
disturbances  as  an  accompaniment  to  the  general  consti- 
tutional symptoms. 

In  this  variety  catarrhal  sym- 
ptoms may  be  entirely  absent. 
The  headache  is  extreme,  de- 
lirium is  usual,  and  the  occur- 
rence of  convulsions  combined 
with  obstinate  vomiting  may 
closely  simulate  meningitis. 

(iv.)  The  Febrile  form.  In 
rare  cases  fever,  either  remittent 
or  continued,  even  for  several 
weeks,  may  be  the  only  mani- 
festation of  influenza. 

(v.)  Chronic  Influenza.  This 
variety  is  often  the  result  of  a 
series  of  acute  attacks  occurring 
within  a  few  weeks  or  months. 
It  is  frequently  afebrile  and 
accompanied  by  a  slow  pulse. 

Though  chronic  bronchial 
catarrh  is  a  usual  accompani- 
ment of  chronic  influenza,  it  is 
nevertheless  by  no  means  un- 
common for  severe  prostration, 
mental  and  physical,  to  be  the 
only  sign. 

Complications.  It  is  by  reason  of  its  complications,  as 
well  as  by  its  predilection  for  elderly  and  debilitated  subjects, 
that  influenza  is  so  dangerous. 

The  common  complications  are  : — 

(i.)  Pulmonary.  Capillary  bronchitis  and  broncho-pneu- 
monia are  often  seen  in  the  respiratory  form  of  influenza. 
Lobar  pneumonia  is  extremely  rare,  though  the  tendency 
for  the  patches  of  lobular  inflammation  to  fuse  into  large 


5 
1 

9. 

1 

m' 

lOs' 
10^ 
103' 

102' 
101' 

IOC 

39° 
98' 
97' 
96' 

1*0 
130 
120 
110 
100 
90 
SO 
70 
60 
•50 
SS 
4S 
35 
25 

M    E 

M   E 

M   E 

M   E 

M    E 

M  E 

M  E 

'- 

•^ 

r 

lA 

A- 

.^. 

V: 

\/-' 

r?" 

^V^ 

^-" 

■ 

': 

: 

A 

J^ 

■/\ 

/ 

"■: 

V\ 

•r- 

— 

^ 

•»" 

»*- 

^ 

::;::: 

i^ 

Fig.   12. — Chart   from   a   typical 
case  of  uncomplicated  Influenza. 


SPECIFIC   INFECTIVE  DISEASES  37 

solid  areas  may  simulate  a  lobar  distribution.  Should  the 
inflamed  area  reach  the  surface,  a  pleurisy  \vi\\  follow, 
but  primary  pleurisy  is  exceptional.  Empyema  may  occur 
in  the  same  manner  as  pleurisy. 

(ii.)  Cardiac.  Endocarditis  and  pericarditis  are  occasion- 
ally found.  Disordered  action  of  the  heart  from  toxic 
myocardial  degeneration  is  frequent.  This  usually  takes 
the  form  of  an  obstinate  bradycardia,  though  tachycardia, 
especially  an  undue  "  exercise  acceleration,"  may  persist 
for  weeks. 

(iii.)  Nervous  System.  Meningitis  is  rare.  Neuritis  is 
common,  both  in  the  isolated  or  int'irstitial  form  and  also 
in  the  parenchymatous  variety.  Obstinate  depression,  or 
even  melancholia,  is  a  frequent  sequel. 

(iv.)  Osteo-arthritic  System.  Arthritis  with  fluid  effusions, 
rarely  becoming  purulent,  may  occur.  Otorrhoea  is  v^erj^ 
common,  and  occasionally  the  mastoid  cells  maybe  involved. 

Diagnosis.  The  only  certain  method  of  diagnosing 
influenza  is  to  recover  the  bacillus  from  the  sputum  or  nasal 
secretion.  When  bronchitis  is  j^ resent  the  sputum  fre- 
quently contains  small  green  purulent  masses  ;  one  of  these 
should  be  spread  on  to  Alms  and  stained  with  carbol- 
fuchsin  as  described  above,  and  also  by  the  method  of 
Gram.  Cidture  tubes  of  blood  agar  should  be  inoculated, 
and  if  necessary  sub-cultures  made  in  forty-eight  hours. 
When  respiratory  catarrh  is  absent  it  will  be  impossible  to 
demonstrate  the  specific  organism  except  in  the  graver 
septicemic  forms  in  which  endocarditis  and  arthritis  are 
present.  In  such  cases  the  bacillus  may  sometimes  be 
recovered  from  the  blood.  Apart  from  bacteriological 
investigations,  the  diagnosis  will  depend  on  the  presence 
of  an  epidemic,  the  possible  history  of  exposure  to  infection, 
the  sudden  onset  with  headache  and  severe  jmins  in  the  hactc 
and  limits,  high  temperature  combined  with  a  fairly  slow 
I)ulse,  and  an  appearance  of  prostration  out  of  all  proportion 
to  the  signs  and  symptoms  present.  There  is  no  leuco- 
cytosis  in  influenza. 

Combined  with  these  general  features  there  will  be  sym- 
ptoms pointing  to  the  involvement  of  either  the  respiratory, 
gastro-intestinal,  or  cerebral  systems. 


38  MEDICAL   DIAGNOSIS 

The  complications  of  influenza  by  themselves  present  no 
special  features  by  which  their  causative  organism  can  be 
recognised,  and  the  history  of  the  illness  is  all-important. 
At  the  same  time  a  persistent  fine-tube  bronchitis,  the 
physical  signs  of  which  are  often  strictly  localised,  is  sugges- 
tive. In  such  cases  every  care  must  be  taken  to  exclude 
tuberculosis. 

Differential  diagnosis.  (i.)  A  thorough  microscopical 
examination  of  the  sputum  will  settle  whether  pulmonary 
or  bronchial  lesions  are  caused  by  influenza,  tubercle,  or 
other  bacilli. 

(ii.)  Lumbar  puncture,  with  cytological  and  bacterio- 
logical examination  of  the  cerebro-spinal  fluid,  will  settle 
whether  meningitis  is  present  or  not. 

(iii.)  Careful  examination  of  the  abdomen,  showing  the 
absence  of  rigidity,  local  tenderness,  and  fixation  should 
exclude  such  acute  abdominal  conditions  as  appendicitis 
or  perforated  gastric  ulcer.  The  gradual  onset,  abdominal 
distension,  enlarging  spleen,  and,  at  the  end  of  the  week,  the 
rose  spots  and  positive  Widal  reaction,  will  settle  the 
question  in  favour  of  enteric  fever  as  against  the  abdominal 
types  of  influenza. 

XIII.  MEASLES. 

Definition.  An  acute  infective  disease  characterised 
by  catarrh  of  the  respiratory  tract,  pyrexia,  and  a  skin 
eruption. 

Bacteriology.  The  specific  organism  has  not  yet  been 
discovered.  The  contagion  is  present  in  the  blood,  in  the 
skin,  and  more  especially  in  the  nasal  and  buccal  secretions. 
The  poison  is  probably  conveyed  in  dust  from  dried  particles 
of  sputum,  hence  infection  by  fomites  is  common. 

Incubation  Period.  Usually  fourteen  days  (seven  to 
eighteen). 

Course.  The  onset,  though  occasionally  insidious,  is 
more  often  abrupt,  with  headache,  malaise,  running  at  the 
eyes  and  nose,  and  bronchitis.  The  temperature  rises 
during  the  first  twenty -four  hours  to  a  height  of  103°  to 
104°  ;  the  pulse  becomes  rapid  and  full  and  the  skin  hot 
and  dry. 


SPECIFIC  INFECTIVE  DISEASES 


39 


The  constitutional  symptoms  increase  in  severity  till  the 
rash  is  fully  developed  at  the  end  of  the  fifth  day,  when  the 
temperature  falls  rapidly,  almost  by  crisis,  and  a  speedy 
convalescence  takes  place.  The  rash  of  measles  occurs  on 
the  fourth  day,  though  in  a  few  cases  it  is  preceded  by  a 
prodromal  eruption,  usually 
in  the  nature  of  a  scattered 
blotchy  erythema. 

The  true  rash  starts  as 
minute  red  papules  in  the 
roots  of  the  hair  along  the 
forehead  and  behind  the  ears  ; 
these  spread  rapidly  over  the 
face,  down  the  trunk  and 
arms,  and  later  along  the 
thighs  and  legs.  The  papules 
increase  in  size  and  run 
together,  forming  irregularly 
crescentic  blotches  separated 
from  each  other  by  areas  of 
healthy  skin. 

Sometimes  the  papules  are 
surmoimted  by  minute  miliary 
vesicles. 

The  rash  is  not  full  y 
developed  for  twenty  -  four 
hours  after  its  first  manifesta- 
tion ;  it  has  a  shottj'  feel  to 
the  examining  finger  and  fades 
on  pressure,  except  when,  as 
rarely  happens,  it  is  the  site  of 
small  petechial  ha'morrhages. 

The  mucous  membrane  of 
the  mouth  is  often  affected  by  the  eruption.  The  fauces 
are  always  injected.  The  rash  fades  gradually  from  the 
seventh  or  eighth  day,  and  is  followed  by  a  fine  ])ranny 
desquamation  lasting  from  one  to  two  weeks. 

Before  tlie  ap])earance  of  the  rash — that  is  to  say,  as  early 
as  the  second  or  third  day — Koplik'a  apots  nuiy  be  recognised 
in  90  per  cent,  of  all  cases.     The  spots  consist  of  red  areola) 


KJ 

1 

1 

to 

^' 

9. 

1 

106' 
105' 
10*' 
103' 

lot 

101' 
100" 
39' 
98' 
37" 
96' 
■>-95' 
1*0 
130 

no 

no 
100 
90 

so 

70 

so 

i-50 
55 
45 
35 
25 

M    E 

M    E 

M    E 

M  £ 

ME 

M  E 

ME 

M  £ 

■A 

A 

■h 

/ 

V- 

\  A 

\ 

,A 

/ 

^  1 

1 

V^ 

J 

\l 

] 

': 

lA 

-w 

•  -a 

■  M* 

>•• 

•— 

-■p- 

•* 

1 

A 

/\ 

■ 

•h 

/^ 

r 

^ 

\ 

1 

l^' 

^ 

A 

r 

-vA 

/: 

'-— 

■^■ 

V 

^ 

1    <~ 

_ 

Fig.  13.— Chart  from  a  case  of 
Measles  showinj^  termination  by 
crisis  at  the  end  of  the  sixth  day 
and  also  increased  fever  after 
the  appearance  of  the  eruption 
on  the  fourth  and  fifth  days. 


40  MEDICAL  DIAGNOSIS 

with  a  bliiish-Avhite  centre  situated  on  the  mucous  membrane 
of  the  cheek  opposite  the  level  of  the  mandibular  premolars. 

There  is  no  leucocytosis  in  measles,  but  myelocytes  are  often 
present  in  small  numbers. 

Varieties.  The  ordinary  form  of  measles  may  be  mild  or 
severe,  but  in  addition  a  malignant  or  black  form  is  described 
in  which  hsemorrhages  take  place  into  the  skin  and  from  the 
mucous  membranes,  and  death  ensues  before  the  end  of  the 
week  with  every  sign  of  profound  cardiac  toxaemia. 

Complications.  The  most  serious  complications  are  those 
of  the  respiratory  tract.  Laryngitis  is  not  infrequent  ;  it 
is  most  common  during  the  second  or  third  weeks,  giving  rise 
to  a  husky  voice,  croupj^  cough,  and  even  to  stridor,  inter- 
costal recession,  cyanosis,  and  the  other  signs  of  severe 
laryngeal  obstruction.  Tracheotomy  may  be  necessary,  but 
as  the  acute  signs  do  not  often  persist  for  more  than  thirty- 
six  hours,  palliative  measures,  or  possibly  intubation,  will 
usually  suffice. 

Bronchitis,  which  is  an  ordinary  manifestation  of  the 
disease,  may  affect  the  capillary  bronchioles  and  produce  a 
suffocative  catarrh,  while  true  broncho-pneumonia,  both  in 
the  acute  stage  and  during  convalescence,  is  a  frequent 
complication. 

Owing  to  the  lowered  resistance  of  the  tissues  as  the  result 
of  these  respiratory  complications,  pulmonary  tuberculosis, 
in  the  form  of  a  tuberculous  broncho-pneumonia,  is  a  com- 
mon sequel. 

Otitis  media,  with  perforation  of  the  tympanic  mem- 
branes and  intractable  otorrhcea,  is  very  common. 

Stomatitis,  and  even  cancrum  oris  (massive  necrosis  and 
gangrene  of  the  cheek  and  gums),  may  occur,  and  is  most 
likely  to  be  met  with  during  the  third  week. 

Acute  nephritis  is  more  common  than  has  been  stated. 

Endocarditis,  arthritis,  hemiplegia,  paraplegia,  and  poly- 
neuritis, though  rare,  are  sometimes  met  with  during  the 
height  of  the  attack. 

Diagnosis.  Measles  is  a  disease  to  which  all  ages  are 
liable,  but  it  is  rare  for  babies  under  three  months  to  be 
affected.  By  far  the  greatest  number  of  cases  are  seen  in 
children  under  twelve  years  of  age.     This  is  largely  due  to 


SPECIFIC   INFECTIVE   DISEASES  41 

the  fact  that  the  widespread  incidence  of  tlie  disease  causes 
the  majority  of  persons  to  be  infected  in  childhood  and  so  to 
acquire  the  relative  immunity  conferred  by  one  attack. 

The  history  of  exposure  to  infection  is  important  ;  for  the 
rest  the  diagnosis  will  depend  on  : — 

(i.)  A  three  days'  coryza  and  bronchial  catarrh  of  sudden 
onset  with  high  temperature. 

(ii.)  Koplik's  spots  on  the  second  or  third  day. 

(iii.)  The  characteristic  rash  on  the  fourth  day. 

(iv.)  The  absence  of  any  leucocytosis  and  the  presence  of 
mj'elocytes  in  the  blood. 

Differential  Diagnosis.  (i.)  Small-pox.  The  nodular 
character  of  the  rash  and  its  early  appearance  on  the  face, 
especially  in  adults,  may  lead  to  this  mistake,  but  in  small- 
pox oculo-nasal  catarrh  and  Koplik's  spots  are  absent,  and 
the  general  condition  of  the  patient,  as  well  as  the  onset 
with  rigor,  vomiting,  and  backache,  is  usually  distinctive. 
Furthermore,  in  small-pox  there  is  always  a  well-marked 
leucocytosis. 

(ii.)  Scarlet  Fever.  In  scarlet  fever  an  onset  with  rigor  is 
almost  invariable.  The  pulse-rate  is  more  rapid  than  that 
of  measles  (160  per  minute)  ;  the  throat  is  affected  rather 
than  the  mouth,  as  in  measles.  The  rash  appears  on  the 
second  day,  starts  at  the  root  of  the  neck,  and  consists  of  a 
diffuse  uniform  erythema  with  no  areas  of  healthy  skin,  such 
as  are  seen  in  measles.  Again,  coryza  is  absent,  and  there 
is  a  leucocytosis. 

(iii.)  German  Measles.  Here  the  onset  is  less  severe  ;  the 
temperature  as  a  rule  is  not  above  100°.  The  rash  appears 
on  the  first  day  ;  the  papules  are  more  discrete,  there  are 
enlarged  glands  in  the  posterior  triangles  of  the  neck,  and  a 
red  macular  eruption  in  the /oMces  is  a  constant  symptom. 

(iv.)  Erythema  Multijorme.  In  appearance  this  may 
closely  resemble  the  rash  of  measles,  but  coryza  and  constitu- 
tional symptoms  will  be  wanting,  or  possibly  definite  signs 
of  rheumatism  may  be  present. 

(v.)  Drug  Rashes  {vide  also  p.  612).  Copaiba  and  the 
injection  of  anti-toxic  sera  may  produce  ra.shes  which  are 
indistinguishable  from  measles,  but  in  the  former  cases  there 
will  be  no  constitutional  disturbance,  and  in  the  latter  the 


42  MEDICAL   DIAGNOSIS 

presence  of  profuse  perspirations  and  joint  pains  will  iisuallj'' 
be  noticed.  In  any  case  the  knowledge  that  copaiba  or 
serum  has  been  used  Avill  usually  prevent  any  error. 

The  erythematous  eruptions  of  septicsemia  may  simulate 
measles,  but  are  more  evanescent  and  do  not  appear  first 
at  the  root  of  the  hair.  Enema  rashes  are  usually  limited 
to  the  trunk  and  are  more  often  scarlatiniform  than  mor- 
billiform. 

XIV.  MUMPS. 

Definition.  A  specific  infective  disease  characterised 
by  painful  swelling  of  the  salivary  glands  and  mild  pyrexia. 

Bacteriology.  The  specific  organism  has  not  yet  been 
discovered.  The  disease  is  highly  infectious  and  confers 
immunity. 

Incubation  Period.     Forty-eight  hours  to  three  weeks. 

Course.  After  a  few  hours  of  slight  fever  and  malaise 
there  is  pain  and  swelling  in  the  region  of  one  parotid 
gland  ;  the  swelling  rapidly  increases,  until  in  twenty- 
four  hours  the  mouth  can  only  be  opened  with  difficulty. 

In  the  majority  of  cases  the  opposite  gland  will  become 
similarly  affected  within  two  or  three  days.  After  a  week 
or  ten  days  the  swelling  gradually  subsides.  The  tempera- 
ture remains  about  100°  or  101°  throughout  the  course  of 
the  disease.  Slight  deafness,  earache,  or  even  otitis  media, 
may  accompany  the  attack.  Suppuration  is  extremely 
rare. 

Although  mumps  nearly  always  selects  the  parotid  gland, 
it  may  occasionally  be  found  in  the  submaxillary  or  sub- 
lingual glands,  while  the  testicles  in  men  and  the  ovaries  in 
women  or  the  breasts  are  sometimes  the  site  of  metastatic 
mumps. 

These  extra -salivary  affections  are  extremely  rare  before 
puberty. 

The  metastatic  swellings  are  most  likely  to  occur  about 
the  eighth  day  ;  sometimes  the  orchitis  jDrecedes  the 
parotiditis,  and  in  rare  cases  it  may  be  the  sole  manifesta- 
tion of  the  disease. 

Diagnosis.     Mumps  is  a  disease  of  childhood  and  adoles-- 


SPECIFIC  INFECTIVE   DISEASES  43 

cence  ;  infants  and  adults  are  rarely  affected.  It  is  most 
frequent  in  autumn  and  spring. 

A  non-suppurative  swelling  of  the  parotid  gland,  passing 
forward  in  front  of  the  ear  and  backwards  beneath  the 
sterno-mastoid  with  elevation  of  the  lobe  of  the  ear,  starting 
on  one  side,  soon  becoming  bilateral,  accompanied  by  mild 
fever  and  occurring  in  a  child,  will  usually  permit  of  no 
other  diagnosis. 

It  must  be  remembered  that  in  rare  cases,  and  more 
especially  in  older  people,  mumps  may  be  peculiarly  severe. 
High  fever,  delirium,  and  extreme  prostration  may  then  be 
met  '\\'ith. 

Differential  Diagnosis.  Any  other  parotid  tumour  is  rare 
in  childhood. 

Parotid  endothelioma  is  unilateral,  of  slow  growth,  much 
harder  than  mumps,  and,  at  first,  unattended  by  any 
constitutional  disturbance. 

Infective  parotiditis  occurs  during  the  course  of  an  acute 
fever,  and  also  as  a  complication  of  any  abdominal  condition, 
such  as  gastric  ulcer,  where  mouth  feeding  may  be  suspended. 
It  is  caused  primarily  by  the  unusually  dry  condition  of  the 
mouth.  Such  swellings  often  suppurate.  This  fact  in 
conjunction  with  the  presence  of  some  other  definite 
pathological  condition  Mill  suffice  to  prevent  the  diagnosis 
of  mumps. 

XV.  LOBAR  PNEUMONIA. 

Definition.  A  specific  infective  disease  characterised  bj'^ 
inflammation  of  one  or  more  lobes  of  the  lungs  and  asso- 
ciated with  profound  toxa'mia. 

Bacteriology.  Acute  inflammation  of  a  lung  with  a 
lobar  distribution  is  not  always  due  to  the  pneumococcus, 
but  the  predominance  of  this  organism  as  the  causative 
factor  is  so  great  that  the  term  "lobar  pneumonia"  is 
generally  understood  to  comprise  this  variety  only. 

The  pneumococcus  of  Fraenkel  is  a  micrococcus  the 
shape  of  which  is  that  of  a  flattened  oval.  It  is  usually 
arranged  in  pairs,  the  two  flattened  surfaces  being  adjacent. 
There  is  a  definite  ca|)snle.  It  stains  with  basic  aniline 
dyes  and  is  not  decolouri.sed  by  the  method  of  Gram. 


44  MEDICAL  DIAGNOSIS 

In  common  with  most  other  so-called  diplococci,  it  is 
best  cultivated  at  the  body  temperature  on  the  medium  of 
fresh  blood  agar,  when  in  thirty-six  hours  characteristic 
small,  almost  transparent,  circular  colonies  make  their 
appearance.  These  run  together  into  a  filmj^  pellicle  with 
isolated  colonies  at  its  margin.  It  is  difficult,  and  some- 
times impossible,  to  get  a  pure  culture  of  a  pneumococcus 
direct  from  the  sputum  of  a  patient,  hence  it  is  sometimes 
necessary  to  inoculate  a  mouse  subcutaneously  with  a  small 


Fig.  14. — Diplococcus  Pneumonise  from  the  peritoneal 
fluid  of  an  inoculated  animal.     Magnification  /.  1000. 

portion  of  the  suspected  material.  In  forty-eight  hours 
the  animal  will  die  of  a  virulent  septicaemia  and  the  cap- 
sulated  diplococcus  can  readily  be  recovered  from  its 
blood. 

Friedlander's  pneumo-bacillus,  a  capsulated  Gram-nega- 
tive bacillus,  is  sometimes  found  in  the  sputum  of  pneumonic 
patients  ;  it  is  very  rare  for  it  to  occur  alone  ;  more  often 
it  is  in  association  with  the  pneumococcus,  for  which, 
however,  it  should  not  be  mistaken. 

Incubation  Period.  From  a  few  hours  to  a  few  days, 
but,  since  case  to  case  infection  is  unusual,  the  incubation 
period  cannot  readily  be  determined. 


SPECIFIC   INFECTIVE  DISEASES 


45 


Course.  The  invasion  is  abrupt,  usually  with  vomiting 
and  a  rigor,  or,  in  the  case  of  young  children,  convulsions. 
In  a  few  hours  there  is  a  sharp  stabbing  pain  in  the  chest, 
worse  on  inspiration,  increased  rapidity  of  respiration,  and 
a  rise  of  temperature  to  from  102°  to  104°.  A  short  dry 
cough,  at  first  unproductive,  will  soon  be  apparent.  By  the 
second  or  third  day  the  clinical  picture  is  usually  charac- 
teristic. The  patient  lies 
flat  on  his  back,  or 
possibly  on  the  affected 
side,  the  face  is  flushed 
except  for  a  circum-oral 
pallor  ;  the  eyes  a  r  e 
bright,  the  expression 
anxious  ;  the  alae  nasi 
dilate  with  each  inspira- 
tion ;  a  labial  herpes  is 
very  common  ;  there  is  a 
short,  distressing  cough 
which  produces  a  scanty 
and  very  tenacious 
.sputum,  at  first  tinged 
with  bright  blood  and 
later  rusty  in  colour. 
Percussion  usually  re- 
veals a  slightly  enlarged 
spleen.  The  temperature 
is  steady,  with  a  slight 
daily  remission,  at  or 
about  104  .  The  pulse 
is  relatively  slow  (105—- 
115),  while  the  respira- 
tions are  extremely  rapid,  usually  about  40  per  minute  for  an 
adult,  00  to  80  for  a  child.  The  pleuritic  pain  often  persists  till 
the  third  or  fourth  day.  The  severity  of  the  symptoms  and 
the  prostration  of  the  patient  increa.se  till  somewliere  be- 
tween the  seventh  and  tenth  days,  when  the  temperature 
returns  to  normal  by  crisis,  the  respiration  rate  falls,  the 
patient  breaks  out  into  a  brisk  perspiration,  and  usually  drops 
into  a  healthy  sleep,  from  which  he  wakes  some  ten  or  twelve 


i 
1 

1 

! 

/06' 
lOS' 
10^ 
103' 
lOi' 
101' 
100° 
39' 
98' 
5/* 
96' 
^9J' 
1*0 
130 

no 

110 
100 
90 
10 
70 

so 

TSO 

ss 

45 
35 

?5 

M    E 

M    E 

ME 

M    E 

M    E 

M  E 

M  E 

ME 

M   E 

M  e 

A 

; 

T 

J 

r- 

y^ 

^ 

I 

1 

V 

\ 

I 

V- 

\ 

/; 

' 

■ 

\ 

\ 

.A 

V       \ 

/^ 

v--- 

' 

/ 

• 

A 

:/ 

y 

\ 

T 

<^ 

\ 

/ 

\ 

L^ 

^ 

/: 

J 

\ 

,^~\ 

' 

V 

N 

ir-A 

v^ 

. 

A 

^ 

■r 

y 

—^ 

\ 

. 

/ 

V- 

\ 

1  . 

•-^ 

Fio.   15. — Chart  from  a  typical  case  of 
Lol)ar  Pneumonia. 


46  MEDICAL  DIAGNOSIS 

hours  later,  weak,  but  free  from  all  distressing  symptoms. 
In  a  certain  proportion  of  cases  the  crisis  may  occur  at  an    ' 
earlier  date,  more  especially  in  the  case  of  children. 

Physical  Signs  in  the  Chest.     The  earliest  physical  sign 
may  be  restricted  movement  of  one  side  of  the  chest.     When 
the  pleuritic  pain  has  appeared  a  friction  rub  can  often  be 
heard.     The  percussion  note   at  first  is  usually   "boxy" 
or  hyper -resonant  ;    this  is  due  to  the  fact  that  the  consoli- 
dation is  apt  to  start  in  the  centre  of  the  lung,  thus  leaving 
a  thin  layer  of  healthy  lung  between  the  affected  portion 
and  the  pleura.     As  the  consolidation  reaches  the  surface 
so    will   the    percussion   note    become   dull    and    woodeny.    j 
The  area  of  dulness,  if  accurately  delimited,  may  be  found    I 
to   correspond   more   or  less   closely   with   the   anatomical    . 
boundaries  of  one  or  more  lobes  of  the  lung.     On  auscultation, 
in    addition    to    the    pleuritic    sounds    already  mentioned, 
there  will  be  localised  r41es  of  fine  and  medium  size.     The    *■ 
air  entry  will  progressively  diminish,  and,  as  consolidation 
advances,  the  breath  sounds  will  acquire  a  tubular  character,    . 
until  at  the  height  of  the  disease  there  will  be  no  sound   ' 
audible  over  the  affected  area,  except  the  tubular  breath 
sounds  of  the  larynx  and  trachea,  which  are  admirably  con- 
ducted to  the  listening  ear  by  the  consolidated  lung.     It  must 
be  remembered,  however,  that  tubular  breathing  is  often  not 
detected  during  the  early  days  of  the  attack.     Medium  and 
coarse  rales,  indicating  bronchitis,  may  generally  be  heard 
over  those  areas  of  lung  which  are  adjacent  to  the  pneumonic 
patch,  and  often  in  the  other  lung  as  well. 

In  some  cases  the  bronchus  leading  to  the  consolidated 
patch  may  be  temporarily  plugged  with  mucous  ;  under 
these  circumstances  tubular  breathing  is  absent. 

Resolution  is  often  delayed  for  several  days  after  the  crisis  ; 
it  is  effected  by  the  liberation  of  autolytic  enzymes  from  the 
disintegrating  leucocytes.  The  inflammatory  mass  is  thus 
softened  by  ferment  action  and  is  for  the  most  part  absorbed 
by  the  lymphatics,  though  a  certain  proportion  is  coughed 
up,  as  is  evidenced  by  the  profuse  rusty-coloured  sputum 
which  is  expectorated  during  this  stage  of  the  disease,  i 
The  process  of  resolution  is  revealed  to  auscultation  by  ] 
the    reappearance    over    the    affected    area   of   fine    sticky 


SPECIFIC   INFECTIVE   DISEASES  47 

crepitations,  which  gradually  increase  in  size  and  moist- 
ness.  These  so-called  redux  crepitations  are  due  to  the 
separation  of  the  alveolar  walls  and  the  opening  up  of 
the  terminal  bronchioles  by  the  re-entering  stream  of 
inspired  air. 

Varieties.  The  following  varieties  of  pneumonia  are 
recognised  clinically  : — 

(i.)  Basal  Pneumonia.  This  is  the  most  common  variety 
and  affects  the  lower  lobe  of  one  or  other  lung.  The  right 
lung  is  more  commonly  affected  than  the  left. 

(ii.)  Double  Pneumonia.  In  this  both  lungs  are  involved. 
It  is  unusual  for  both  lungs  to  be  affected  simultaneously, 
the  second  lung  usually  being  attacked  after  an  interval 
of  several  days. 

(iii.)  Apical  Pneumonia.  In  this  variety  it  is  the  upper 
lobe  which  is  affected.  It  is  far  more  common  on  the  right 
side  than  on  the  left,  and  is  most  frequently  seen  in  children. 
Delirium  and  meningismus  are  particularly  liable  to  occur 
in  this  variety. 

(iv.)  Central  Pneumonia.  In  this  variety  consolidation 
is  restricted  to  the  central  portion  of  the  lobe  and  may  not 
reach  the  surface  at  all.  As  a  result  the  physical  signs  in  the 
chest  may  be  few  or  none,  while  the  clinical  picture  will 
be  that  of  undoubted  pneumonia. 

(v.)  Migratory  or  Creeping  Pneumonia.  In  this  some- 
what rare  variety  the  signs  of  resolution  in  one  part  will  be 
accompanied  by  those  of  developing  consolidation  in  an 
adjacent  area.  In  consequence  the  temperature  chart  is 
likely  to  show  a  number  of  pseudo-crises,  and  the  disease 
will  appear  to  have  terminated  by  lysis.  This  variety  is 
more  frequently  associated  with  the  influenza  bacillus 
than  with  the  pneumococcus. 

(vi.)  Terminal  Pne2imonia.  Lobar  ])i)eumonia  may  some- 
times occur  as  a  terminal  event  in  elderly  or  debihtated 
siil)jects,  though  it  is  not  so  common  in  this  connection 
as  is  a  lobular  type  of  inflammation.  The  initial  weakness 
of  the  patient  may  prevent  an  adequate  reaction  to  the 
infection — that  is  to  say,  there  may  be  little  or  no  increase 
in  either  the  ra])idity  of  the  res])irati()n,  or  the  height  of 
the    temperature,    while    the    primary    illness    may    make 


48  MEDICAL   DIAGNOSIS 

systematic  examination  difficult,  with  the  inevitable  result 
that  this  condition  may  easily  escape  recognition  during 
life.  It  is  probable  that  other  organisms  than  the  pneumo- 
coccus  are  often  the  cause  of  this  variety  of  lobar  pneumonia. 

(vii.)  Asthenic  Pneumonia.  In  addition  to  the  terminal 
variety  it  may  sometimes  happen  that  a  given  individual, 
though  apparently  healthy,  may  be  affected  with  lobar 
pneumonia  and  yet  fail  to  show  the  usual  temperature  and 
respiration  reaction.  At  the  same  time  the  ordinary  leu- 
cocytosis  will  not  be  found.  This  variety  is  particularly 
fatal,  and  chronic  alcoholism  should  be  suspected  in  such 
cases. 

Complications.  Two  main  classes  of  complications  can  be 
recognised  in  lobar  pneumonia. 

First,  local  complications  affecting  the  thoracic  viscera 
and  secondly  metastatic  inflammations  indicating  a  pro- 
found septicaemia. 

(i.)  Local  Complications,  (a)  Delayed  Resolution.  The 
crisis  may  not  occur  until  the  third  week.  On  the  other 
hand,  even  when  the  crisis  has  occurred  at  the  normal  time, 
the  physical  signs  of  consolidation  may  persist  for  several 
weeks.  In  many  such  cases  there  will  be  little  or  no  con- 
stitutional disturbance,  but  in  others  there  may  be  persistent 
pleuritic  pain,  dry,  hacking  cough,  with  scanty  expectora- 
tion, sweatings,  and  irregular  pyrexia.  In  a  very  small 
proportion  of  cases  fibrosis  of  the  inflammatory  exudate  may 
lead  to  contraction  of  the  chest,  and  ultimately  a  fibroid 
lung  may  develop  with  the  probable  accompaniment  of 
bronchiectasis. 

(6)  Abscess  of  the  Lung  and  Gangrene  of  the  Lung.  It 
occasionally  happens  that  the  patient  is  deficient  in  the  power 
of  manufacturing  autolytic  enzymes.  Resolution  is  there- 
fore prevented,  while  the  collection  of  dead  and  dying 
leucocytes  affords  a  favourable  pabulum  for  the  multiplica- 
tion of  secondary  organisms  such  as  strepto-  and  staphylo- 
cocci. The  natural  result  is  the  formation  of  an  abscess  cavity 
within  the  lung.  In  more  severe  cases  gangrene  may  take 
place  in  the  affected  part.  (*linically  the  supervention  of  a 
septic  type  of  temperature,  with  profuse,  perspirations,  etc., 
combined  with  the  appearance  of  a  foul  purulent  expectora- 


SPECIFIC   INFECTIVE   DISEASES  49 

tion  and  the  persistence  of  a  duU  area  in  the  King,  may  lead 
to  the  diagnosis  of  the  abscess.  In  the  case  of  gangrene  the 
sputum  will  be  profuse,  watery,  and  of  a  dark  plum  colour 
(so-called  "  prune-juice  ")  ;  this,  with  its  peculiar  and 
unforgettable  odour,  which  is  also  imparted  to  the  breath  of 
the  patient,  will  leave  no  room  for  errpr. 

(c)  Pleurisy.  A  fibrinous  pleurisy  is  the  rule  in  lobar 
pneumonia.  A  few  ounces  of  turbid  yellow  fluid  are  usually 
poured  out.  Occasionally  the  effusion  may  be  much  more 
abundant  ;  the  ordinary  signs  of  pleural  effusion  will  then 
be  apparent.  Sometimes  so  much  fibrin  is  formed  that  the 
lung  sounds  are  more  or  less  completely  cut  off. 

{d)  Emjjyejna.  During  the  second  week  of  pneumonia,  or 
later,  pneumococcal  empyema  may  occur.  If  the  crisis  has 
occurred,  the  temperature  will  rise  again  and  become 
irregular  in  type.  Rigors  may  occur,  and  the  patient  will 
be  worried  by  a  frequent  throaty  cough  and  repeated 
perspirations.  The  physical  signs  will  be  considered  under 
"  Differential  Diagnosis  "  (p.  53). 

(e)  Pericanlitis.  This  is  usually  a  complication  of  left- 
sided  basal  pneumonia,  the  infection  spreading  by  direct 
extension  through  the  parietal  pericardium.  Since  the 
inflammation  is  usually  purulent  from  the  commencement, 
pericardial  friction  may  not  be  audible.  The  diagnosis  is 
therefore  extremely  difficult,  and  will  depend  upon  increasing 
dyspnoea,  tachycardia,  and  the  other  signs  of  cardiac  dilata- 
tion, with  possibly  nniffling  of  the  heart  sounds  and  a 
triangular  area  of  cardiac  dulness  as  the  effusion  increases  in 
amount.  Pericarditis  may  also  occur  as  a  metastatic 
septicemic  inflammation  apart  from  direct  extension. 

(ii.)  ^Metastatic  or  SKPTiciEMic  Complications. 
(a)  Ulcerative  Endocarditis.  The  symptoms  of  this  con- 
dition will  be  the  same  as  those  of  ulcerative  endocarditis 
starting  in  any  other  maimer.  The  pneumococcus  is  second 
only  to  the  streptococcus  in  the  frequency  with  which  it 
produces  this  disease.  In  the  nuijority  of  cases  it  is  possible 
to  recover  the  organism  from  the  blood. 

{h)  Pericarditis  {vide  supra). 

(r)  Art/irifis.  Pain  and  swelling  of  one  or  more  joints, 
with  a  rapid  elfusion  which  often  becomes  ])urident,  occurring 

M.D.  4 


50  MEDICAL  DIAGNOSIS 

in  the  course  of  a  lobar  pneumonia  will  leave  little  doubt  as 
to  the  nature  of  the  organism  at  fault. 

(rZ)  Meningitis.  Meningitis  in  the  course  of  a  pneumonic 
septicaemia  is  rapidly  fatal.  The  inflammation  is  usually 
vertical.  The  intractable  headache  and  vomiting,  the 
tendency  to  convulsions  and  paralyses,  together  with  the 
rapid  development  of  unconsciousness,  will  suggest  the 
diagnosis.  Lumbar  puncture  will  show  an  excess  of  poly- 
morphonuclear leucocytes,  while  the  pneumococcus  may  be 
demonstrated  in  the  film  preparations  and  may  be  culti- 
vated either  directly  or  after  inoculation  of  a  mouse. 

In  this  connection  it  must  not  be  forgotten  that  pneumonia, 
and  especially  apical  pneumonia  in  children,  may  from  pure 
toxaemia  present  a  clinical  picture  of  so-called  meningismus 
which  will  very  closely  resemble  true  meningitis. 

In  such  cases  the  cerebral  symptoms  will  completely 
disappear  with  the  crisis,  while,  if  necessary,  the  diagnosis 
can  be  settled  at  any  time  by  lumbar  puncture,  when  normal 
cerebro-spinal  fluid  will  be  obtained. 

(e)  Peritonitis.  This  complication  is  rare  ;  it  is  most 
frequently  seen  in  children.  It  is  of  remarkably  sudden 
onset,  the  peritoneum  appearing  to  fill  up  with  pus  in  a  few 
hours.  There  will  usually  be  more  or  less  abdominal  pain, 
often  referred  to  the  umbilicus  and  accompanied  by  diarrhoea. 
The  rapid  supervention  of  extreme  distension  and  rigidity 
will  excite  suspicion  as  to  the  true  state  of  affairs.  It  must, 
however,  be  clearly  understood  that  in  many  cases  of  plain, 
uncomplicated  lobar  pneumonia  the  earliest  symptoms  may 
be  abdominal  pain  and  diarrhoea. 

Diagnosis.  Attention  should  be  paid  to  the  following 
characteristics  of  an  attack  of  pneumonia  : — - 

(i.)  The  History.  The  sudden  onset  with  rigor  and  vomit- 
ing, followed  in  a  few  hours  by  cough  and  a  pain  in  the  side. 

(ii.)  The  Appearance.  The  flushed  face  and,  bright  eyes, 
labial  herpes,  rapid  respirations,  and  the  attitude  (low  down 
in  the  bed,  either  on  the  back  or  side). 

(iii.)  The  Temperature.  The  temperature  rises  suddenly 
to  103''  or  104°  ;  it  remains  at  this  level  with  a  slight  remis- 
sion for  from  seven  to  ten  days,  when  it  falls  by  crisis  to 
below  normal.     In  many  cases  there  is  a  rise  of  one  or  two 


f 


SPECIFIC   INFECTIVE   DISEASES  51 

degrees  on  the  day  following  the  crisis,  after  which  the 
temperature  returns  to  normal  and  remains  there. 

(iv.)  The  Respiration.  The  frequency  of  the  respirations 
is  much  increased,  more  so  in  children  than  adults  (35  to  60), 
but  there  is  no  true  difficulty  of  respiration. 

(v.)  The  Pulse.  The  pulse  (about  110)  is  relatively  slow 
considering  the  temperature.  The  pulse  respiration  ratio 
is  much  diminished — that  is  to  saj^  instead  of,  as  in  healthy 
people,  being  about  4  to  1,  in  pneumonia  it  is  usually  about 
5  to  2. 

(vi.)  The  Blood.  There  is  a  well-marked  polymorpho- 
nuclear leucocytosis,  the  white  cells  usually  number  from 
30,000  to  40,000  per  cubic  mm.  This  leucocytosis  appears 
within  the  first  twenty-four  hours  and  persists  till  shortly 
after  the  crisis. 

(vii.)  The  Urine.  The  urine  is  concentrated,  scanty  and 
high  coloured.  The  chlorides  are  much  diminished  afnd 
often  entirely  absent. 

This  retention  of  the  chlorides  occurs  to  some  extent 
in  many  acute  febrile  disorders  and  also  in  starvation,  but 
not  to  the  same  extent  as  in  pneumonia. 

(viii.)  Measurement.  The  affected  side  of  the  chest  will 
usually  measure  from  \  inch  to  |  inch  more  than  the  sound 
side.  The  measurement  is  best  taken  from  the  tip  of  the  fifth 
dorsal  spine  to  the  middle  line  in  front. 

(ix.)  Tlie  Sputum.  For  twenty-four  hours  there  is  but 
little  sputum,  and  what  there  is  is  thick,  sticky,  and  tena- 
cious. On  the  second  and  third  days  the  sputum  is  more 
abundant,  viscid,  and  often  streaked  with  brightish  blood  ; 
for  the  next  three  or  four  days  the  sputum  becomes  freer, 
more  copious  and  contains  more  blood.  The  blood  is  more 
diffused  and  of  a  darker  colour.  As  resolution  takes  place 
the  sputum  becomes  very  abundant,  more  fluid,  and  is 
often  of  a  uiiiforni  dark  red-brown  coloration. 

Differential  Diagnosis,  (i.)  From  othkr  Acute  Specific 
Fevers.  At  the  outset  it  may  be  difficult,  and  especially 
so  in  children,  to  diagnose  ])neumonia  from  scarlet  fever, 
measles,  etc.  The  pulse  respiration  ratio  is  quite  different, 
while  the  early  appearance  of  pain  in  the  side,  or  pleuritic 
rub  (III  tlu-  one  hand,  and  sooner  or  later  of  the  eruption  on 

4—2 


52  MEDICAL  DIAGNOSIS 

the  other,  will  usually  be  sufficient.  In  those  cases  of 
abortive  pneumonia  where  no  physical  signs  in  the  chest 
are  present  throughout  the  illness  the  diagnosis  of  pneumonia 
may  depend  entirely  on  the  rapidity  of  the  respirations, 
the  aspect  and  attitude  of  the  patient,  the  possible 
presence  of  herpes,  and  the  diminution  of  chlorides  in  the 
urine. 

(ii.)  From  Enteric  Fever  {vide  p.  24). 

(iii.)  From  Cerebral  Conditions,  (a)  Meningitis  {vide 
p.  7). 

{h)  Delirium  Tremens.  Though  delirium  tremens  does 
not  bear  any  resemblance  clinically  to  lobar  pneumonia, 
nevertheless  it  is  well  worthy  of  note  that  in  chronic  alcoholics 
delirium  tremens  is  a  particularly  common  complication  of 
pneumonia,  and  may  indeed  be  the  first  visible  sign  of  this 
affection  ;  it  is  therefore  particularly  important  to  make  a 
thorough  examination  of  the  lungs  in  all  cases  of  delirium 
tremens. 

(iv.)  From  other  Pulmonary  Conditions,  {a)  Pleurisy, 
witJiout  Effusion.  The  constitutional  symptoms  are  not 
so  severe.  The  temperature  is  more  irregular,  the  affected 
side  is  not  increased  in  girth,  the  signs  of  consolidation  do 
not  appear. 

Since  a  large  proportion  of  cases  of  primary  pleurisy  are 
in  reality  due  to  tuberculosis,  the  special  tests  for  this 
condition  {vide  p.  105)  will  often  give  a  positive  result. 

(6)  Pleural  Effusion.  Where  there  is  fluid  in  the 
pleural  sac  the  cardiac  apex  beat  is  displaced  towards  the 
sound  side.  The  percussion  note  over  fluid  is  more  abso- 
lutely dull  than  over  the  solid  lung  ;  it  is  woolly  rather  than 
wooden.  The  breath  sounds  are  cut  off  partially  or  entirely, 
while  tubular  breathing,  if  present,  is  usually  only  to  be 
heard  at  the  upper  limit  of  the  dull  area.  The  area  of 
duiness  does  not  follow  in  shape  the  anatomical  boundaries 
of  the  pulmonary  lobes.  Above  the  dull  area  will  be  a 
skodaic  percussion  note,  and  here  the  voice  sounds  will  have 
a  nasal  twang.  An  encysted  collection  of  fluid  may  be 
more  difficult  to  diagnose,  since  it  is  more  likely  to  have  been 
present  for  a  considerable  time  ;  under  these  circumstances 
secondary  collapse  of  the  lung  may  lead  to  contraction  of 


SPECIFIC  INFECTIVE   DISEASES  53 

that  side  of  the  chest,  and  the  apex  beat,  so  far  from  being 
displaced  to  the  sound  side,  may  actually  be  pulled  over 
towards  the  lesion.  By  very  reason  of  its  chronicity  the 
clinical  picture  of  pneumonia  will  be  wanting,  the  respira- 
tions will  not  be  hurried,  and  the  patient  may  not  appear 
acutely  ill.  In  any  case  of  doubt  the  diagnosis  may  be 
settled  by  exploration  with  a  hollow  needle.  The  point  of 
maximum  dulness  should  be  selected  for  the  puncture  {vide 
also  "  Pleural  Effusion,"  p.  306). 

(c)  Empyema.  The  above  remarks  re  pleural  effusion 
apply  for  the  most  part  to  empyema,  but  it  must  be  remem- 
bered that  empj^ema  is  often  localised  and  frequently  starts 
between  the  lobes  of  the  lung  ;  further,  tubular  breathing 
is  often  more  extensive  over  a  purulent  collection  than 
over  a  serous  effusion. 

The  following  features  may  prove  of  service  in  the  diag- 
nosis of  empyema  as  against  pneumonia  : —  / 
(i.)  (Edema  of  the  chest  wall, 
(ii.)  An  irregular  or  septic  temperature, 
(iii.)  Frequent  perspirations. 

(iv.)  A  lower  leucocyte  count,  viz.,  15.000  to  20,000. 
(v.)  A  throaty  and  unproductive  cough, 
(vi.)  An  X-ray  examination  will  show  a  more  complete 
opacity  and  a  more  complete  immobility  of  the  diaphragm 
on  the  affected  side  where  pus  or  fluid  is  present  than 
where  the  lung  is  solid. 

It  remains  to  say  that  it  is  often  impossible  to  settle  the 
diagnosis  except  by  exploratory  puncture. 

(d)  Collapse  of  Lung.  Extensive  collapse  of  lung  may 
give  the  same  physical  signs  as  inflammatory  consolidation. 
It  may  occur  quite  suddenly  in  the  cour.se  of  a  broncho- 
pneumonia. Again,  pericarditis,  or  anything  which  inter- 
feres with  the  proper  action  of  the  diaphragm,  e.g.,  peri- 
tonitis, may  cause  extensive  basal  collapse  in  one  or  both 
lungs.  Except  when  the  collapse  is  caused  by  pleural 
effusion  or  pneumothorax,  the  affected  side  of  the  chest 
will  measure  less  than  the  sound  side.  In  most  cases  of 
pulmonary  co]la])se  there  will  be  no  leucocytosis,  neither 
will  the  patient  a])pear  so  acutely  ill  as  in  ])neumonia. 

(e)  Acute  Pneumonic  Pulmonary  Tuberculosis.     This  alfec- 


54  MEDICAL  DIAGNOSIS 

tion  is  most  frequently  seen  in  the  upper  lobe,  and  exactly 
resembles  an  apical  lobar  pneumonia  in  its  mode  of  onset, 
physical  signs,  and  in  the  aspect  of  the  patient.  It  is  indeed 
an  acute  inflammation  of  the  lung  with  a  lobar  distribution, 
only  it  is  caused  by  the  tubercle  bacillus,  not  by  the 
pneumococcus. 

The  following  points  may  lead  the  observer  to  suspect  the 
true  state  of  affairs,  though  it  may  be  impossible  to  verify 
the  diagnosis  for  several  days  : — 

(i.)  The  pulse  respiration  ratio  may  not  be  so  profoundly 

altered,  and  the  absolute  pulse-rate  is  often  under  100  per 

minute. 

(ii.)  The  temperature  may  show  greater  variations  than 

in  true  pneumonia. 

(iii.)  Herpes  labialis  is  not  so  common. 

(iv.)  There  may  be  little  oj  no  sputum  at  first. 

(v.)  There  will  be  no  crisis. 

(vi.)  During  the  se'cond  week,  if  the  patient  survives, 

the  temperature  will  show  an  extreme  daily  variation  ; 

there  are  likely  to  be  perspirations,  and  later  the  patient 

may    begin    to    expectorate    large    quantities    of    liquid 

purulent  sputum  in  which  enormous  numbers  of  tubercle 

bacilli   can  be   found.     By   this   time   definite   signs   of 

cavitation  may  be  manifest. 

(v.)  Feom  Abdominal  Conditions.  The  first  symptoms 
of  lobar  pneumonia  may  be  abdominal  in  character.  Pain, 
diarrhoea,  and  vomiting  are  not  infrequent.  In  children  the 
pain  may  be  referred  to  the  abdomen  throughout  the  disease. 
In  many  cases  this  is  due  to  the  pleuritic  involvement, 
causing  the  pain  to  be  referred  along  the  course  of  the  inter- 
costal nerves. 

Should  the  disease  be  on  the  right  side,  appendicitis  may 
be  suspected. 

The  diagnosis  can  usually  be  settled  by  a  careful  examina- 
tion of  the  lungs  as  well  as  of  the  abdomen.  It  will  be  found 
that  there  are  no  objective  signs  in  the  abdomen,  and  if 
rigidity  be  present  it  will  be  voluntary  rather  than  reflex, 
whereas  there  will  be  restricted  movement  on  one  side  of 
the  chest,  even  if  there  is  no  more  definite  indications  of 
pneumonia.     The  leucocytosis  is  higher  in  pneumonia  than 


SPECIFIC   INFECTIVE   DISEASES  55 

in  acute  abdominal  conditions,  and  in  the  latter  there  is  no 
diminution  in  urinary  chlorides  unless  the  patient  has  been 
starved. 

The  shallow  nature  of  the  quickened  respirations,  as  well 
as  the  attitude  of  the  patient,  should  afford  confirmatory 
evidence  of  the  true  site  of  the  lesion. 

XVI.  RELAPSING  FEVER. 

Definition.  A  specific  infective  disease  characterised  by 
sudden  onset,  high  temperature,  crisis  and  a  relapse  occurring 
one  week  later. 

Bacteriology.  The  disease  ^-^        ^  v^ 

is  due  to  the  Spirillum  or 
Spirochseta  Obermeieri.  a 
member  of    the  protozoa.  ^ 

the  length  of  which  is  about  .^m^ 
three  times  the  diameter  of  .^V 
a  red  blood  cell.  '^U 

During  the  height  of  the  \^^  / 

fever  the  organism    is        ^  a... 

present  in  the  blood-stream, 

from  which   it   disappears  * 

after  the  crisis. 

It     has     not      yet      been      Fig.   16.-8i.iniluni  nl.  n.Kieri  in  the 

•^  blood  ot   a  i>atifnt    intcctcu   with 

cultivated,  but  can  readih'  Relapsing  Fever.     Magnification  X 

be   demonstrated   in  ordi- 

nary  blood  films  stained   by  the  method   of   Giemsa   {vide 

p.   155). 

Incubation  Period.     From  a  few  hours  to  three  weeks. 

Course.  The  onset  is  sudden,  with  rigor,  headache, 
backache,  giddiness,  and  vomiting.  Joint  and  muscle  pains 
are  frequent.  Though  constipation  is  the  rule,  diarrhoea 
may  be  troublesome. 

The  temperature  quickly  rises  to  from  104  to  los  .  The 
skin  is  jaundiced  :  the  liver  and  spleen  are  enlarged  and 
tender.  Occasionally  there  is  an  eruption  of  small  rose-pink 
papules  on  the  trunk  and  shoulders.  The  temperature 
remains  high  for  about  a  week,  when  it  falls  by  crisis,  usually 
f  o  \)ii^  or  07°.     At  the  time  of  crisis  there  arc  profuse  perspira- 


56  MEDICAL   DIAGNOSIS 

tions,  diarrhoea  and  diuresis,  while  occasionally  there  may 
be  bleeding  from  the  mucous  membranes. 

In  a  few  days  the  temperature  has  risen  to  normal  and  the 
patient  feels  quite  well,  but  about  the  seventh  day  from  the 
crisis  there  is  another  attack  in  all  respects  similar  to  the 
first,  except  that  it  is  usually  about  two  days  shorter. 
Commonly  there  is  but  one  relapse,  but  there  may  be  several. 

Complications.  Haemorrhage  from  the  mucous  membranes 
may  be  severe,  while  the  diarrhoea  may  assume  a  dysenteric 
form  ;  otherwise  the  complications  are  those  of  any  other 
acute  fever. 

Diagnosis.  The  history  of  an  epidemic  or  of  exposure 
amid  surroundings  of  squalor  and  destitution  are  important. 
Adolescence  is  the  most  likely  age  for  infection  to  occur. 

The  course  of  the  disease,  with  its  relapse  on  the  fourteenth 
day,  is  quite  characteristic,  while  the  discovery  of  the 
organism  in  the  blood  of  the  patient  will  leave  no  further 
room  for  doubt. 


XVII.  RHEUMATIC  FEVER. 

Acute  and  Subacute  Rheumatism. 

Definition.  A  specific  infective  disease  characterised  by 
irregular  pyrexia,  perspirations  and  inflammation  of  fibrous 
tissues,  particularly  in  the  joints  and  heart. 

Bacteriology.  Its  specific  organism  has  not  with  certainty 
been  identified,  but  Poynton  and  Paine  have  described  a 
diplococcus  which  they  claim  to  have  recovered  from  the 
blood,  heart,  joints,  etc.,  of  rheumatic  patients. 

It  is  probable  that  the  infection  enters  the  blood-stream 
via  the  tonsils. 

Course.  The  onset  is  usually  abrupt,  with  headache, 
malaise  and  a  rapid  rise  of  temperature,  but  rigors  are 
extremely  rare.  At  the  same  time  there  is  pain,  swelling,  and 
tenderness  in  a  joint,  usually  one  of  the  larger  joints,  such 
as  the  knee,  shoulder,  or  ankle.  In  a  few  hours  the  pain  and 
swelling  will  leave  the  joint  first  affected  and  appear  in 
another  one  and  so  on.  The  temperature  remains  irregular, 
and  the  patient  suffers  from  repeated  profuse  perspirations. 


SPECIFIC   INFECTIVE   DISEASES 


57 


The  tongue  is  moist  and  covered  with  a  thick  white  fur  ;   the 
urine  is  high-coloured,  febrile,  and  scanty. 

The  heart  is  affected  in  two  ways  : — ^First,  the  severity 
of  the  infection  produces  a  mj'ocarditis,  with  consequent 
dilatation  at  some  period  during  the  course  in  the  great 
majority  of  cases.  Secondly,  about  30  per  cent,  of  all  cases 
of  rheumatic  fever  which  start  with  arthritis  develop  a 
true  vegetative  endo- 
carditis of  one  or  more 
valves,  the  result  being 
permanent  valvular  de- 
formity to  a  great  or  less 
extent.  Anaemia  d  e  - 
velops  early  in  the  course 
of  the  disease,  and  a  well- 
marked  leucocytosis  is 
the  rule.  The  course  of 
rheumatic  fever  extends 
throughout  six  to  ten 
weeks,  a  period  that 
is  not  appreciably 
shortened  by  treatment, 
though  the  temperature 
is  reduced  and  the 
patient  kept  free  from 
I)ain  by  the  use  of 
salicylates. 

It     is     worth  y     o  f 
emphasis    that    arthritis 
is  not  a  necessary  accom- 
})animent    of    rheumatic     Fig.    17.    Chart    from    a    case    of    Acute 
fever  ;      indeed,      the  Rhcumatis.u  in  which  Salicylates  were 

'  '  not  administered  till  the  fourth  day. 

younger  the  patient  the 

more  likely  is  it  for  myo-  and  endo-  carditis  to  be  the  most 

])r<)Miinent  features  of  tlu'  case. 

Other  Manifestations  of  Rheumatism,  (i.)  Sore  Throat. 
JioDi  tonsillitis  and  catairhal  inllamination  of  the  fauces 
and  pharynx  are  commonh'  met  with. 

(ii.)  Rheumatic  Noihde.s.  These  arc  small  masses  of 
fibrous  tissue  attached  to  the  periosteum  or  tendon  sheaths 


1 

f 

1 

m' 

lOS' 
10^ 

m' 
lot 

101' 

IOC 

39' 
9B' 

96' 

1*0 
130 
120 

no 
100 
90 
SO 
70 
60 

'" 

ss 

45 
35 

c 

M    E 

H   E 

M   E 

M  E 

M    E 

ME 

M  E 

M  E 

M   E 

ME 

A 

/\ 

/^ 

b 

7- 

^\ 

J. 

\A 

: 

V' 

- 

\/^ 

,    \ 

.«• 

-r- 

... 

•-• 

-<-• 

"^" 

v.: 

T^-^ 

r~' 

■\ 

A 

A 

sl-' 

.^ 

/ 

/\ 

^ 

^■ 

, 

"^- 

-r- 

•r- 

••• 

"T" 

■»•' 

••• 

v^ 

-■•■ 

-T" 

.^ 

ZA 

V^ 

^*"'  "1 

■"* 

-^ 

- 

58  MEDICAL  DIAGNOSIS 

close  under  the  skin.  They  are  seen  particularly  on  the 
elbows,  knuckles,  knees  and  other  bony  proininences  ;  they 
usually  persist  for  a  few  weeks  only.  It  is  very  rare  for  them 
to  occur  in  the  first  attack  of  rheumatic  fever  ;  they  are 
therefore  of  grave  prognosis. 

(iii.)  Skin  Eruptions.  Sweat  rashes  are  common,  but 
are  not  specifically  rheumatic. 

Erythema  multiforme  is,  however,  frequently  seen  in 
children,  though  it  is  not  common  in  adults.  Purpura 
rheumatica  (Schoenlein's  disease)  consists  of  showers  of 
minute  subcutaneous  haemorrhages  about  the  trunk  and 
limbs. 

(iv.)  Pericarditis.  This  may  occur  at  any  stage  of  rheu- 
matic fever  ;  it  may  indeed  be  the  first  manifestation  of  the 
disease.  The  inflammation  is  usually  sero-fibrinous,  and 
an  adherent  pericardium  is  a  common  sequel. 

(v.)  Pleurisy  is  not  common  ;  there  is  usually  little 
or  no  effusion. 

(vi.)  Chorea.  This  is  usually  regarded  as  a  rheumatic 
infection  of  the  cerebral  cortex  ;  certainly  its  age  incidence 
is  that  of  rheumatic  fever,  while  it  is  frequently  seen  in 
association  with  rheumatism,  and  it  is  often  complicated  by 
endocarditis. 

Complications,  (i.)  Hyperpyrexia — that  is  to  say,  a 
temperature  remaining  for  more  than  a  few  minutes  at  a 
higher  level  than  106° — is  a  serious  complication  of  rheuma- 
tism, though,  fortunately,  it  is  rare.  It  is  more  common 
in  men  than  women,  and  in  the  first  attack  of  rheumatism. 
It  does  not  occur  in  children. 

(ii.)  Cerebral  Rhemnatism.  By  this  is  meant  rheumatism 
accompanied  by  marked  delirium  or  other  cerebral  symptoms. 
It  is  very  rare,  and  when  present  is  not  infrequently  accom- 
panied by  hyperpyrexia.  It  must  be  remembered  that 
salicylates  may  give  rise  to  delirium  in  susceptible  subjects. 

Diagnosis.  In  adults  the  diagnosis  depends  upon  the 
sudden  onset  of  illness,  with  pain  and  inflammation  flitting 
from  joint  to  joint,  profuse  acid  perspirations  with  their 
characteristic  odour,  the  irregular  pyrexia,  and  the  rapid 
development  of  anaemia. 

It  must  be  remembered  that  rheumatic  fever  is  a  disease 


.SPECIFIC   INFECTIVE   DISEASES  59 

of  children  and  young  adults,  and  that  it  is  rare  for  a  first 
attack  to  occur  after  the  age  of  thirty. 

In  children  there  may  be  more  difficulty  in  establishing 
the  diagnosis,  for  although  there  will  usually  be  a  history 
of  transient  limb  pains,  in  many  cases  all  joint  inflammation 
will  be  absent  ;  the  acid  perspiration  is  well  marked,  and 
the  anaemia  is  even  more  severe  than  in  adults.  Again, 
examination  will  frequently  reveal  a  tonsillitis  or  some 
cardiac  lesion.  Any  case  of  prolonged  or  oft-recurring 
pyrexia  without  obvious  cause  in  a  child  should  arouse  sus- 
picion of  rheumatism.  In  all  cases  a  careful  history  should  be 
obtained,  for  there  seems  little  doubt  that  heredity  plays  an 
important  part  in  the  rheumatic  diathesis,  and  it  is  extremely 
connnon  for  brothers  and  sisters  to  be  affected. 

Lastly,  the  history  of  a  previous  attack  of  rheumatism 
is  important,  as  one  attack  undoubtedly  predisposes  to 
another. 

Special  Features,  (i.)  The  Joints.  The  larger  joints  are 
usually  affected  ;  their  characteristic  serial  involvement  has 
already  been  mentioned.  The  affected  joints  are  swollen, 
puffy,  hot  and  extremely  tender.  Ordinarily  there  is 
little  or  no  alteration  in  colour,  though  there  may  be  a  faint 
pink  blush.  They  contain  a  slightly  turbid  fluid,  but  do  not 
suppurate  ;   neither  is  there  any  permanent  deformity. 

(ii.)  The  Heart.  Rheumatism  is  by  far  the  commonest 
cause  of  so-called  "  Simple  Endocarditis."  This  is  likely 
to  occur  during  the  height  of  the  attack.  Since  the  mitral 
is  the  valve  most  often  affected,  mitral  murmurs,  systolic 
or  diastolic,  are  commonly  the  first  signs  that  endocarditis 
is  present.  It  is,  however,  necessary  to  remember  that 
cardiac  dilatation  is  very  often  present  from  myocardial 
intoxication,  and  that  a  systolic  murmur  of  passive  mitral 
regurgitation  is  likely  to  be  met  with  without  there  being 
of  necessity  any  structural  valve  change.  It  will  be  im})os- 
siblo  to  differentiate  these  (tonditions  ujitil  the  end  of  the 
illness,  by  which  time  the  heait  will  have  recovered  from 
any  passive  dilatation,  or  will  have  accommodated  itself 
to  meet  the  ret^uii'emcnts  of  a  damaged  valve  leaving  i)er- 
manent  signs  thereof,  such  as  hypertrophy  and  ])ersistent 
murmurs. 


60  MEDICAL  DIAGNOSIS 

Lastly,  a  true  hsemic  bruit,  systolic  in  time  and  of  maxi- 
mum intensity  at  the  pulmonary  area,  may  occur  as  the 
direct  result  of  the  ansemia  and  will  disappear  as  the  anaemia 
is  relieved. 

Differential  Diagnosis,  (i.)  Froyn  Acute  Gout.  Gout 
attacks  much  older  people  ;  it  affects  smaller  joints,  which 
are  shiny,  cedematous  and  purple,  often  with  distended 
veins  running  over  them. 

(ii.)  Fro7n  Gonorrhoeal  Arthritis  {vide  p.  33). 

(iii.)  From  Acute  Rheumatoid  Arthritis.  Here  the  smaller 
joints  are  likely  to  be  affected,  and  there  is  not  the  same 
tendency  for  the  swelling  to  wander  from  joint  to  joint. 
Permanent  peri -articular  thickening  commonly  results. 
The  particular  odour  of  rheumatic  perspiration  is  likely  to 
be  wanting. 

(iv.)  From  PycBmia.  A  septic  focus  is  commonly  present, 
the  metastases  are  not  necessarily  limited  to  joints,  and 
when  joints  are  affected  they  are  likely  to  suppurate. 

(v.)  From  Scarlatinal  Arthritis.  Clinically  these  joints 
may  be  indistinguishable  from  those  of  rheumatism,  but  as 
a  general  rule  the  presence  of  peeling  or  history  of  scarlet 
fever  should  prevent  error. 

(vi.)  From  Osteoynyelitis.  This  is  likely  to  occur  at  the 
lower  end  of  the  femur  or  the  upper  end  of  the  humerus. 
There  is  often  a  history  of  injury.  The  affected  part  may 
be  red  and  cedematous,  rigors  are  probable  (these  do  not 
occur  in  rheumatism),  and  careful  examination  will  reveal 
the  fact  that  the  joint  itself  is  not  affected  by  the  inflapima- 
tory  process. 

It  remains  to  say  that  the  differential  diagnosis  of  multiple 
arthritis  is  often  extremely  difficult  and  that  the  diagnosis 
of  rheumatism  can  sometimes  only  be  made  after  the  ten- 
tative exhibition  of  salicylates,  which  seem  to  exert  a  specific 
action  in  relieving  the  pain  and  reducing  the  inflammation  of 
joints  affected  by  this  disease. 

XVIII.  SCARLET  FEVER.  , 

Definition.  A  specific  infective  disease  particularly 
affecting  children,  characterised  hy  a  sudden  onset,  a  sore 
throat,  and  a  red  rash. 


SPECIFIC  INFECTIVE   DISEASES 


61 


Bacteriology.  The  specific  micro-organism  has  not  yet 
been  identified,  but  it  has  long  been  thought  to  be  a  strep- 
tococcus. An  additional  evidence  in  favour  of  this  view 
is  furnished  in  the  favourable  results  reported  from  the 
treatment  of  certain  of  the  more  severe  cases  of  septic  scarlet 
fever  by  the  administration  of  protective  sera  that  have  been 


i 

1 
!^ 

r 
1 

! 

106° 

lers' 

10*' 

m' 

lOZ' 
101° 
100° 
39° 
S8° 

9r 

96° 

1*0 
130 
120 
no 
100 
90 

to 

70 

so 
rso 
ss 

45 
3S 
25 

M    E 

M    E 

M   E 

M    E 

M    E 

M  E 

M  E 

M  E 

M   E 

M   E 

M   E 

M  t 

M  E 

ME 

; 

■  r 

'S 

\ 

/\ 

vA 

\/ 

\: 

: 

\A 

^ 

; 

- 

{/' 

1 

\/\ 

; 

V 

k^ 

^^ 

1   A 

A 

•  ••- 

.— . 

.mk. 

•— • 

•■r- 

'•f' 

... 

._. 

— - 

•••• 

.^. 

^? 

u 

'^ 

h/^ 

■/ 

; " 

^■ 

V^ 

"^ 

V^ 

^ 

\,^ 

\ 

\: 

\ 

■•• 

•  •• 

-^- 

■^- 

-r- 

•*m 

— 

■»• 

•  *• 

- 

*■ 

•T» 

-T" 

.-. 

... 

■^ 

V 

V^ 

^ 

"^^ 

A 

■^ 

v_ 

~~ 

Fig.  18. — Chart  from  a  case  of  Scarlet  Fever. 

obtained  from  animals  immunised  against  streptococci  from 
the  throats  of  scarlet  fever  patients. 

Incubation  Period.  One  to  seven  days  (usually  two  or 
three). 

Course.  The  invasion  is  abrupt,  with  rigor,  vomiting, 
and  sore  throat.  In  very  young  children  there  may  be 
convulsions.  The  temperature  rises  on  the  first  day  to 
103° — 104°,  The  skin  is  hot  and  pungent,  and  the  ])ulse 
is  exlrettiehj  rapid,  100  to  180  jK^r  minute.     On  the  second 


62  MEDICAL   DIAGNOSIS 

day  the  rash  appears  ;  it  consists  of  two  parts — a  diffuse 
bhish  and  minute  punctate  papules.  It  appears  first  at 
the  root  of  the  neck  and  spreads  rapidly  over  the  entire  body. 
On  the  face,  the  palms  of  the  hands,  and  the  soles  of  the 
feet  the  papular  element  is  absent,  the  blush  alone  being 
present,  while  the  skin  around  the  mouth  escapes  altogether 
(circum-oral  pallor). 

The  rash  starts  to  fade  about  the  fourth  day,  and  as  it 
fades  a  desquamation  commences  which  may  continue  for 
weeks  or  even  months. 

The  fauces  are  intensely  injected,  and  on  the  tonsils  there 
is  usually  a  yellowish  exudate  ;  the  cervical  glands  are 
generally  enlarged.  The  tongue  at  first  is  moist  and  covered 
with  white  fur,  through  which  project  the  swollen  papillae  ; 
but  by  the  second  or  third  day  the  fur  has  disappeared, 
leaving  a  glazed  surface  on  which  the  elevated  papillae  are 
distinctly  visible.  The  constitutional  symptoms  increase 
in  severity  till  the  fourth  day,  when  as  the  rash  begins  to 
fade  so  does  the  temperature  come  down  by  lysis  and 
the  patient  feels  better. 

A  slight  febrile  albuminuria  is  common  during  the  height 
of  the  disease.     A  definite  leucocytosis  is  invariable. 

Varieties.  In  addition  to  the  ordinary  form  described 
above  the  following  varieties  of  scarlet  fever  may  be  met 
with. 

(i.)  Septic  or  Anginose  Variety.  In  this  form  there  is 
extensive  ulceration  of  the  throat,  the  secondary  cervical 
adenitis  is  extremely  severe,  the  glands  often  break  down, 
and  ulceration  and  necrosis  of  the  cutaneous  tissues  in  the 
neck  may  follow. 

(ii.)  The  Toxic  or  MaUgna7it  Variety.  Here  there  are 
symptoms  of  profound  toxaemia,  and  delirium  is  common, 
while  haemorrhagic  spots  and  even  death  may  precede  the 
true  eruption. 

Complications,  (i.)  Otitis  Media.  This  is  due  to  the 
spread  of  infection  up  the  eustachian  tube.  The  chief 
symptom  is  earache,  and  in  a  little  while  examination  of 
the  ear  reveals  a  bulging  membrana  tympani.  If  the 
membrane  is  not  incised,  it  will  rupture  and  a  purulent 
otorrhoea  will  result. 


SPECIFIC   INFECTIVE  DISEASES  63 

(ii.)  Pulmonary  Complications.  Pleurisy,  pneumonia,  and 
even  empyema  may  in  rare  cases  follow  scarlet  fever. 

(iii.)  Cardiac  Complications.  Endocarditis  and  peri- 
carditis have  been  described.  In  the  septic  variety  an 
ulcerative  endocarditis,  just  as  in  septicaemia  from  any  other 
cause,  may  supervene. 

(iv.)  Nephritis.  An  acute  glomerular  nephritis  is  a 
common  complication  in  the  second,  third,  or  fourth  weeks 
of  scarlet  fever.  It  must  not  be  confounded  with  the  febrile 
albuminuria  of  the  first  week. 

The  nephritis  may  be  of  such  severity  that  there  is  sup- 
pression of  urine,  and  the  child  dies  in  a  few  days  with  aU 
the  symptoms  of  acute  uraemia.  More  commonly  there  is 
oedema  of  the  face  and  extremities,  the  urine  is  smoky  and 
contains  tube  casts  and  albumin,  and  the  case  becomes  one 
of  chronic  parenchymatous  nephritis.  With  proper  treat- 
ment, however,  recovery  occurs  in  the  majority  of  cases. 

It  is  important  to  remember  that  in  certain  epidemics  of 
scarlet  fever  there  may  be  cases  of  nephritis  due  to  the  scarlet 
fever  toxin,  but  occurring  in  patients  who  have  shown  no 
other  sign  of  the  disease. 

(v.)  Arthritis,  (a)  An  acute  suppurative  pyaemic  joint, 
part  of  a  septicaemia,  and  so  to  be  looked  for  in  the  septic 
type  of  case. 

(6)  A  multiple  arthritis  analogous  to  rheumatism  or 
gonorrhceal  infection  occurring  in  the  second  or  third  week 
and  tending  to  affect  many  joints,  particularly  the  smaller 
joints  of  the  hands  and  feet. 

Diagnosis.  The  tendency  of  scarlet  fever  to  affect 
children  between  the  ages  of  one  and  ten  is  significant  ; 
babies  under  one  usually  escape.  The  history  of  exposure  to 
infection  is  important. 

In  the  early  cases  the  diagnosis  nuist  rest  on  the  sudden 
onset,  particularly  with  vomiting,  the  rapid  rise  of  tempera- 
ture, the  extremely  rapid  pulse  (temperature,  104°  ;  pulse, 
IGO),  the  dry  and  pungent  skin,  and  the  presence  of  an 
injected  throat. 

The  a])pearance  of  the  characteristic  rash  on  the  second 
day  will  clinch  the  diagnosis,  but  the  type  of  rash  is  by  no 
means   constant.     Tlie   papular   element    may   be^  entirely 


64  MEDICAL  DIAGNOSIS 

absent.  The  severity  and  persistence  of  the  rash  in  the 
groins  and  axillae  are  important  points.  While  the  tongue 
is  furred,  it  is  of  no  special  diagnostic  value,  but  a  glazed 
papillated  tongue  combined  with  bright  red  injected  fauces 
and  tonsillar  exudate  is  of  great  value.  It  is  not  too  much 
to  say  that  any  erythematous  eruption  occurring  in  a  child 
on  the  second  day  after  the  onset  of  sudden  illness  with 
vomiting,  should  be  regarded  as  potentially  scarlet  fever. 

In  late  cases,  but  in  the  absence  of  desquamation,  there  are 
often  present  circumscribed  dark-brown  raised  patches  on 
the  outer  aspects  of  the  shins  and  upper  arms  ;  these  are 
considered  to  be  diagnostic  of  scarlet  fever  and  are  said  to  be 
present  in  50  per  cent,  of  all  cases. 

When  there  is  desquamation  it  is  important  to  consider 
the  nature  of  the  peeling,  for  many  conditions  other  than 
scarlet  fever  are  followed  by  this  process. 

The  following  types  of  desquamation  are  more  than  sug- 
gestive of  scarlet  fever  : — 

(i.)  Glove  Peeling — that  is  to  sa}^,  massive  shedding  of  the 
cuticle  of  fingers  and  toes. 

(ii.)  Ring  Peeling.  This  is  best  seen  on  the  chest  and 
shoulders. 

(iii.)  Desquamation  of  any  sort  starting  on  the  hands  or 
feet  from  two  to  three  weeks  after  a  generalised  eruption. 

Differential  Diagnosis,  (i.)  From  Measles  {vide  "  Measles," 
p.  41). 

(ii.)  Fro7n  German  Measles.  In  this  disorder  there  is 
usually  little  or  no  constitutional  disturbance,  and  even  if 
the  temperature  is  high  it  is  not  accompanied  by  such  an 
extremely  rapid  pulse,  as  in  scarlet  fever.  Again,  the  rash 
appears  first  on  the  face,  where  papules  can  easily  be  recog- 
nised, whereas  in  scarlet  fever  the  rash  is  first  seen  on  the 
chest  and  neck,  while  the  papular  element  is  altogether 
wanting  from  the  face.  Diffuse  glandular  enlargement, 
especially  in  the  posterior  cervical  triangles,  is  almost 
invariable  in  German  measles,  while  in  scarlet  fever  the 
enlargement  is  limited  to  the  submaxillary  glands. 

(iii.)  From  Diphtheria.  It  must  be  remembered  that  a 
toxic  erythema  may  occur  in  diphtheria,  that  there  may  be  a 
severe  membranous  inflammation  of  the  fauces  in  scarlet 


SPECIFIC    IXEECTIVE   DISEASES  65 

fever,  and  lastly  that  diphtheria  and  scarlet  fever  may 
coexist.  As  a  general  rule  it  may  be  stated  that  a  dull 
earthy  toxsemic  appearance  with  a  low  temperature  is  in 
favour  of  diphtheria,  while  a  flushed  face  and  dry  pungent 
skin  and  a  high  temperature  is  in  favour  of  scarlet  fever. 
Further,  the  erythema  of  diphtheria  is  limited  to  the  trunk, 
is  less  persistent,  and  of  a  darker  colour  than  the  rash  of 
scarlet  fever.  Bacteriological  examination  of  the  thioat 
will  settle  whether  diphtheria  is  present  or  not  {ride  also 
"Diphtheria,"  p.  13). 

(iv.)  From  Follicular  TonsiUitis.  This  disease  is  not  very 
common  in  young  children  ;  it  may,  however,  be  associated 
with  a  patchy  erythema. 

Though  the  onset  is  abrupt,  initial  vomiting  is  rare.  If 
seen  early,  yellowish  points  may  be  seen  localised  to  the 
tonsillar  crypts  of  one  side  ;  there  is  extreme  dysphagia  arvd 
a  severe  aching  pain  down  both  sides  of  the  neck.  Lastly, 
in  follicular  tonsillitis  the  glazed  papillated  tongue  is  always 
absent  and  the  erythema  which  is  occasionally^  present  is 
but  rarely  followed  by  desquamation. 

(v.)  From  Small-pox.  In  this  disease  a  rosy  eruption  will 
occasionally  be  seen  on  the  second  day  ;  the  rash  is,  however, 
usually  of  a  purple  tint  and  confined  to  the  lower  abdomen, 
groins  and  thighs.  Throat  symptoms  are  ab.sent.  It  should 
not  be  forgotten  that  hemorrhagic  small-pox  and  haemor- 
rhagic  scarlet  fever  are  indistinguishable  from  one  another, 
since  in  both  cases  intense  toxaemia  accompanied  by  a  pur- 
puric rash  may  cause  death  before  the  characteristic 
symptoms  of  the  true  infection  have  had  time  to  manifest 
themselves.  The  presence  of  an  epidemic  of  one  or  other 
disease  may  be  the  only  clue  available. 

(vi.)  From  Drug  Rashes.  Certain  drugs  and  therapeutic 
agents  may  produce  a  scarlatiniform  eruption  ;  the  most 
important  of  these  are  belladonna,  quinine,  salicylates, 
chloral,  boracic  acid,  and  the  enema  rash.  For  the  most 
part  any  accompanying  symptoms  will  be  referable  to  the 
toxic  action  of  the  drugs  concerned — for  example,  delirium 
and  dilated  jiupils  from  l)elladoima,  deafness  and  tinnitis 
from  quinine  and  salicylates. 

(vii.)   F'rom   Erythema  Scarlat  in  {forme  (Acute  Exfoliative 

M.D.  5 


6i6 


MEDICAL  DIAGNOSIS 


Dermatitis).  At  first  this  condition  may  be  indistinguish- 
able from  scarlet  fever,  but  peeling  starts  much  earlier, 
often  on  the  second  day,  and  the  eruption  tends  to  persist 
for  several  weeks  {vide  p.  607). 

XIX.  SMALL-POX. 

Definition.     An    acute    infective    disease    occurring    in 
epidemics  and  characterised  by  a  sudden  onset  and  an  erup- 


1 

1 

fc! 
<u 

r 
.1 

! 

lOS' 
105° 
10*° 
103° 
102' 
101° 

M    E 

M    E 

M  e 

M   E 

M    E 

M  E 

M  e 

M  E 

M   E 

M  6 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

ME 

M  E 

/^ 

'A 

\: 

T 

sJ:^ 

A 

\ 

'a 

. 

V:A 

,     \ 

A 

\ 

/: 

/ 

4 

V  ' 

J\ 

i\ 

Vi, 

/ 

^^ 

s/ 

V 

/a 

99° 
98° 
97° 
96' 
\95° 
ItO 
130 
120 

no 

100 
90 
SO 
70 
60 
<fSO 
55 
45 
35 
2S 

[/' 

V: 

V 

s/^ 

,<^ 

•r- 

.^. 

•"•' 

.*. 

-'^• 

.m. 

... 

.^. 

•-• 

••- 

•t- 

■  w. 

■  ■■ 

.*. 

k^_ 

: 

: 

A 

r 

y^ 

A 

A 

\i 

,  >• 

^ 

/ 

V: 

\ 

/^ 

A 

,A 

K 

r 

— ^ 

\  A 

/ 

/ 

>,A 

V 

^A 

*.   : 

-■f- 

-r- 

-*• 

: 
-•• 

"■^• 

•-• 

••- 

•■^• 

■■■ 

--■ 

.^. 

--- 

■^" 

.— 

— 

. 

,/^ 

-f^ 

^ 

^_^ 

^ 

^^ 

■  S 

^ 

,  ^~ 

V— ^ 

^■"^ 

^ 

-H 

■-■; 

Fig.  19. — Chart  from  a  case  of  Small-iiox  showing  remission  on  the 
third  day  when  tlie  eruption  aj)pears. 

tion  which  passes  through  the  stages  of  papule,  vesicle,  and 
pustule. 

Bacteriology.  No  specific  micro-organism  has  been  identi- 
fied, but  the  researches  of  Guarnieri,  Councilman  and  others 
tend  to  support  the  view  that  the  causative  factor  may  be  a 
protozoon,  the  Cytoryctes  Variolse,  which  is  found  in  the  skin 
lesions, 


SPECIFIC    INFECTIVE   DISEASES  67 

Incubation  Period.     Seven  to  fifteen  days,  usually  twelve. 

Course.  The  invasion  is  abrupt,  with  rigors,  vomiting, 
headache,  and  severe  pain  in  the  loins.  In  children  the 
rigor  is  replaced  b}'  convulsions. 

The  temperature  rises  to  103°  on  the  first  day.  Sometimes 
there  is  a  prodromal  rash,  morbilliform,  scarlatiniform 
or  petechial,  which  is  often  locahsed  to  the  bathing- 
drawers  area  or  to  the  extensor  surfaces  of  the  arms  and  legs. 

The  true  small-pox  eruption  appears  on  the  third  day, 
and  with  its  appearance  the  constitutional  symptoms  abate. 

The  rash  is  seen  as  discrete  round  or  oval  papules.  These 
are  chiefly  found  on  the  face  and  WTists  and  gradually 
extend  to  the  trunk  and  mucous  membranes.  The  papules 
can  be  felt  as  small  nodules  in  the  skin  before  they  are 
visible. 

On  the  sixth  day  the  papules  vesiculate  ;  the  vesicles 
are  multilocular,  and  so  have  an  umbilicated  appearance. 

On  the  ninth  day  the  vesicles  suppurate,  the  temperature 
rises,  and  constitutional  symptoms  return  ;  the  j^ustules 
increase  in  size  and  become  surrounded  by  a  red  inflamed 
areola. 

On  the  twelfth  day  the  pustules  dry  up  with  or  without 
rupture  and  crusts  are  formed,  which  drop  off  during  the 
next  three  or  four  weeks,  to  leave  either  no  mark  or  the 
characteristic  pitted  scar,  according  to  the  depth  of  skin 
which  has  been  involved  in  the  inflammation. 

Tiie  temperature  declines  by  lysis  from  the  fourteenth 
to  eighteenth  days.  There  is  a  definite  leucocj'^tosis  from  the 
eighth  day  onwards. 

Varieties,  (i.)  Ordinary  Small -pox.  This  may  be  divided 
into  two  forms — the  discrete^  as  described,  and  the  confluent. 
In  the  latter  form  the  remission  of  symptoms  as  the  rash 
appears  is  less  marked,  the  papides  are  set  close  together, 
and  when  the  stage  of  suppuration  is  reached  the  pocks 
run  together  and  form  large  scabby  blotches.  The  earlier 
the  first  appearance  of  the  rash  the  more  likely  is  it  to  become 
confluent. 

(ii.)  HiEMORRHAGic  Small-pox.  This  is  described  as  occur- 
ring in  two  forms  : — 

(a)  Black  or  Malignant  Sinall-pox  (Purpura  Variolosa), 

5—2 


68  MEDICAL  DTAGNOSTR 

In  this   form    an  erythematous  rash   and  hsemorrhages 

beneath  the  skin  and  from  the  mucous  membranes  precede 

the  papular  eruption  and  death  ensues  in  from  two  to 

six  days. 

(6)  Purpura  Hcemorrhagica  Pustulosa.     In  this  variety 

the   haemorrhages   do   not  occur  until   the   vesicular  or 

pustular  stage,  and  take  place  at  first  into  the  areolae 

surrounding     the    pocks.       Mucous    ha?morrhages    soon 

follow  and  death  usually  occurs  during  the  second  week. 

(iii.)  Vaeioloid,  or  small-pox  occurring  in  the  vaccinated. 
This  as  a  rule  is  a  comparatively  mild  infection.  The  onset 
is  abrupt  and  the  temperature  reaches  103°  ;  the  papules 
appear  on  the  third  day  and  are  often  confined  to  the  face 
and  hands.  The  disease  often  aborts  in  the  vesicular 
stage,  and  secondary  fever  is  slight  or  absent. 

Complications,  (i.)  Laryngitis.  This  is  the  result  of  the 
pocks  originating  in  the  mucosa  of  the  larynx.  Q^^dema  of 
the  glottis,  or  even  perichondritis,  may  follow.  Aspiration 
broncho -pneumonia  is  predisposed  to  by  the  laryngeal 
affections. 

(ii.)  Pleurisy,  empyema,  and  broncho-pneumonia  may 
occur. 

(iii.)  Conjunctivitis  was  very  common  in  former  years. 
Keratitis  and  blindness  not  infrequently  resulted.  It  is 
probable  that  the  pocks  do  not  occur  on  the  conjunctiva 
or  cornea. 

Diagnosis.  If  there  is  an  epidemic,  the  sudden  onset  of 
illness,  with  rigor,  vomiting,  and  pain  in  the  back,  should 
suggest  small -pox.  It  may,  however,  be  difficult  for  a  time 
to  differentiate  Small-pox  from  : — 

(i.)  Chicken-pox  {vide  p.  8). 

(ii.)   Typhus  {vide  p.  113). 

(iii.)  Measles  {vide  p.  41). 

(iv.)  Cerebrospinal  Meningitis.  When  associated  with 
marked  purpuric  symptoms  this  disease  may  be  mistaken 
for  a  hsemorrhagic  form  of  small -pox.  The  characteristic 
fluid  withdrawn  by  lumbar  puncture  will  determine  the 
point  {vide  p.  512). 

(v.)  Pustular  Syphilides.  These  are  usually  scanty  on 
the  face     and    are    not   preceded  by  such    severe   initial 


SPECIFIC   INFECTIVE   DISEASES  69 

symptoms  as    in  small-pox.     Wassermami"s  reaction  {vide 
p.  76)  will  furnish  important  evidence, 
(vi.)  Pustular  Glanders  {vide  p.  32). 

XX.  SYPHILIS. 

Definition.  A  specific  infective  disease  characterised 
by  three  more  or  less  definite  stages  and  lesions  of  extreme 
diversity,  persisting  or  recurring  throughout  many  years. 

Bacteriology.  The  causative  organism  is  a  protozoon, 
the  Treponema  pallidum,  which  is  actively  motile  and  has 
the  appearance  of  a  tightly  rolled  cork-screw.  The  length 
of  the  organism  is  about  15  {x,  and  there  are  at  least  five 
spirals  to  a  length  equivalent  to  the  diameter  of  a  red 
blood-cell.  The  Treponema  can  easily  be  recognised  in 
the  discharges  from  primary  and  secondary  syphilitic 
lesions,  in  the  viscera  of  congenitally  syphihtic  babies,  and 
occasionally  in  gummata. 

It  has  only  recently  been  cultivated  outside  the  body, 
and  syphilis  has  resulted  from  its  inoculation  into  man  and 
also  the  higher  apes. 

Incubation  Period.  Up  to  eight  weeks  (most  commonly 
twenty  to  thirty  days). 

Varieties,     (i.)  Acquired  Syphilis. 

(ii.)  Congenital  Syphilis. 

Course,     (i.)  Acquired  Syphilis. 

Trimaey  Syphilis.  The  primary  sore  commences  as  a 
small  red,  raised  papule  at  the  site  of  inoculation,  which  is 
commonly  about  the  corona  glandis,  often  near  the  frenum, 
in  the  male,  and  not  infrequently  on  the  labium  minus 
in  the  female.  Extra-genital  chancres  are,  however, 
common,  and  there  is  no  part  of  the  body  that  may  not  be 
so  affected. 

The  papule  grows  in  extent,  and  in  a  few  days  develops 
into  a  shallow  ulcer  with  a  tlat  or  slightly  excavated  top 
and  a  hard  irregular  margin.  The  base  feels  like  either 
parchment  or  gristle,  according  to  its  thickness  ;  there  is 
usually  some  shght  secretion,  which  may  dry  into  a  scab, 
but  occasionally  a  red  papery  papule  is  the  only  sign  of  the 
disease.     There  is  a  painless  enlargement  of  the  neighbouring 


70  MEDICAL   DIAGNOSIS 

inguinal  glands,  and  sometimes  the  lymphatics  on  the  dorsum 

of  the  penis  become  palpable. 

In  ten  or  twelve   weeks,   if  untreated,   the   sore  heals, 

leaving  a  thin  papery  scar. 

Secondary    Syphilis.      Secondary    symptoms    become 

manifest    about    six    weeks    after   the    appearance    of  the 

primary  sore.     They  comprise  : — 

(a)  Constitutional  disturbance  ;  this  may  be  severe, 
but  more  usually  is  limited  to  transient  pyrexia  and 
malaise. 

(6)  Cutaneous  Syphilides.  Any  form  of  skin  eruption 
may  occur.  The  most  common  is  a  roseolar  rash,  best 
seen  on  the  abdomen  and  forehead,  the  palms  of  the 
hands  and  soles  of  the  feet  ;  papular  rashes  are  not 
infrequent  ;  squamous  rashes  resembling  psoriasis  occur, 
but  the  scales  are  less  shiny,  the  underlying  surface  is 
more  coppery,  and  the  knees  and  elbows  are  not  so 
frequently  involved.  The  pustular  syphilide,  apart  from 
the  history  of  the  disease,  may  closely  resemble  the  pus- 
tules of  small-pox. 

It  is  important  to  note  that  secondary  syphilitic 
eruptions  do  not  itch,  are  usually  symmetrical,  leave 
a  coppery  pigmentation  on  fading,  and  tend  to  come  and 
go  at  intervals  of  weeks  or  months  during  the  two  or  three 
years  following  infection. 

(c)  Affections  of  Mucous  Membranes  and  Muco- 
cutaneous Junctions.  A  sore  throat  is  the  most  common 
manifestation  of  secondary  syphilis.  There  may  be  simple 
injection  of  the  fauces,  tonsillitis,  or  painless  symmetrical, 
white,  superficial,  "  snail-traclv ''  ulcers  on  the  palate 
and  fauces. 

Mucous  patches  are  localised  inflammatory  areas  in 
the  mucosa  of  the  mouth,  nose,  anus,  or  vulva.  In  these 
regions  the  papillse  are  frequently  hypertrophied,  forming 
the  so-called  "  syphilitic  wart  "  ;  if  from  excess  of 
moisture  these  cedematous  papillse  fuse  together,  a  sodden 
mass  or  "  condyloma  "  is  the  result. 

(d)  Affections  of  the  Lynvphatic  Glands.  There  is 
commonly  a  diffuse,  moderate  enlargement  of  the  lym- 
phatic   glands    throughout    the    body.     They    are    hard, 


SPECIFIC   INFECTIVE  DISEASES  71 

discrete  and  shotty.  Of  special  significance  is  enlarge- 
ment of  the  gland  above  the  inner  condyle  of  the  humerus 
and  of  those  in  the  posterior  cervical  triangles. 

(e)  Other  Manijestations.  Iritis,  if  present,  usually 
occurs  in  the  first  six  months  of  the  disease  ;  both  eyes 
are  generally  involved,  one  soon  after  the  other. 

Osteo-copic  pains  are  shooting  pains  in  the  long  bones 
and  are  most  complained  of  in  the  night .  Painless  effusion 
into  the  joints  may  occasionally  be  present. 

Loss  of  hair  (alopecia)  and  chronic  inflammation  of 
the  nails  may  be  seen,  while  anaemia  may  be  severe.  As 
a  general  rule  secondary  symptoms  cease  after  about 
eighteen  months. 

Tertiary  Syphilis.  Tertiary  lesions  or  gummata  com- 
monly occur  about  three  or  four  years  after  infection. 
This  form  of  the  disease  may  affect  any  tissue  in  the  body, 
and  is  prone  to  recur,  often  at  long  intervals,  throughout 
a  great  many  years. 

The  typical  gumma  is  a  greyish-yellow  semi -translucent 
mass,  surrounded  by  granulation  tissue  and  fibrous  tissue, 
and  tending  to  undergo  softening  and  caseation  in  the  centre. 
If  the  skin  or  nmcous  membranes  are  affected,  d.eep  indolent 
ulcers  will  result.  Not  infrequently  a  tough  yellow  slough 
may  be  visible  at  the  bottom  of  such  an  ulcer.  Occasionally 
the  scabs  will  collect  one  above  the  other  on  a  syphilitic 
ulcer  and  produce  limpet-shaped  crusts  or  "  rupia." 

Ordinarily  there  is  an  interval  of  immunity  from  symptoms 

between   the   secondary   and   tertiary   manifestations,   but 

sometimes  there  are  frequent  slight  relapses  or  "  reminders." 

Some  special  manifestations  of  tertiary  syphilis  may  here 

be  mentioned. 

(a)  Periostitis.  Syphilitic  nodes  are  locahsed  inflam- 
matory masses  occurring  in  the  periosteum,  usually  on 
the  shafts  of  the  long  bones.  Secondary  infection  may 
lead  to  necrosis  and  abscess  formations,  or  the  swelling 
may  quiet  down  into  a  hard  bony  nodule. 

(6)  Circulatory  System.  Gummatous  mesarteritis  is  a 
fertile  source  of  atheroma,  and  so  plays  an  important 
part  in  the  etiology  of  aneurysm. 

Endarteritis  obliterans  is  perha})s  most  maiked  in  the 


72  MEDICAL   DIAGNOSIS 

cerebral  and  coronary  arteries.  It  consists  in  prolifera- 
tion of  the  intima  and  consequent  occlusion  of  the  vessels. 
It  often  results  in  cerebral  thrombosis  or  fibroid  disease  of 
the  heart.  Hemiplegia  from  syphihtic  cerebral  thrombosis 
is  most  common  within  ten  years  of  the  primary  infec- 
tion. 

(c)  The  Respiratory  System.  Gummatous  ulceration 
of  the  larynx  usually  occurs  in  the  later  stages  of  the 
disease.  It  is  characterised  by  a  thick,  husky  voice  and 
freedom  from  pain. 

Gumma  of  the  lung  is  uncommon,  but  stenosis  of  a 
bronchus  or  of  the  trachea,  the  result  of  syphilitic  ulcera- 
tion, is  more  often  seen. 

Primary  necrosis  of  the  nasal  bones  with  secondary 
involvement  of  the  mucous  membranes  and  cartilages 
causes  nasal  obstruction  and  a  foul  discharge,  while 
serious  deformity  is  a  natural  result. 

{d)  The  Alwientary  System.  The  most  frequent 
manifestation  here  is  stricture  of  the  rectum.  It  is  most 
common  in  women,  is  usually  quite  near  the  anus,  and 
results  from  the  cicatrisation  of  gummata  which  have 
originated  in  the  sub -mucous  tissues. 

Gummata  in  the  liver  may  yield  no  signs  or  symptoms  ; 
sometimes,  however,  a  nodular  enlargement  of  the  liver 
may  be  apparent,  and  in  exceptional  cases  jaundice  or 
ascites  may  result  from  pressure  on  the  hepatic  duct  or 
portal  veins  respectively. 

(e)  Nervous  System.  In  addition  to  the  arterial  disease 
mentioned  above,  gummata  may  develop  in  the  pia  mater. 
They  may  be  either  single  or  multij)le. 

Pressure  on  the  brain  or  spinal  cord  will  produce  the 
characteristic  symptoms  of  tumour  in  these  regions. 
There  may  also  be  diffuse  gummatous  menuigitis,  which 
tends  to  involve  the  nerve  roots  where  they  leave  the 
bram  stem  or  cord.  This  inflammation  usually  involves 
the  pia  mater  around  the  brain,  but  in  the  cord  the  dura 
mater  is  especially  affected,  the  resulting  condition  being 
known  as  "  Pachy -meningitis  "  {vide  also  p.  542). 
Parasyphllitic  Affections.  Tabes  dorsalis,  general 
paralysis  of  the  insane,  and  certain  forms  of  spinal  paralysis 


SPECIFIC   INFECTIVE   DISEASES  73 

have  been  shown  to  occur  only  in  people  who  have  had 
syphilis.  These  diseases  are  called  parasj^hilitic  affections, 
because  the  patients  may  have  been  free  of  any  clinical 
sign  of  syphilis  for  very  many  years  ;  at  the  same  time  the 
spirochsete  has  been  demonstrated  in  the  brain  and  cord  of 
patients  with  general  paralysis,  and  is  probably  present  in 
tabes  also. 

Lardaceous  disease  may  be  a  sequel  of  acquired  syphihs 
if  proper  treatment  has  not  been  carried  out. 

(ii.)  Congenital  Sypliilis.  There  is  no  manifestation  of 
acquired  syphilis  which  may  not  be  met  Avith  in  the  congenital 
form,  including,  in  rare  cases,  tabes  and  general  paralysis  of 
the  insane. 

As  a  general  rule  the  child  is  born  healthy,  though  in 
exceptional  cases  bullous  and  other  eruptions  may  be 
visible  at  birth.  More  commonly  the  first  sign  is  "'  snuffles," 
occurring  in  the  second  to  eighth  week  of  life  and  probably 
accompanied  by  a  red  scaly  rash  on  the  buttocks,  feet,  and 
other  parts.  The  rash  often  has  a  coppery  red  colour  and 
is  sometimes  of  a  papulo -squamous  variety,  and  is  then 
likened  to  raw  ham. 

The  snuffles  may  proceed  to  ulceration  and  necrosis  of  the 
nasal  bones,  while  mucous  patches  are  commonly  present 
about  the  anus,  nioiith  and  eyes.  As  these  heal  fissured 
cracks  are  formed  ("  rhagades  '"),  and  permanent  scarring 
may  result. 

Periosteal  nodes,  especially  about  the  cranial  fontanelles, 
are  common,  as  also  is  deficient  ossification  in  the  centres  of 
the  membraneous  portions  of  the  skull. 

There  may  be  acute  infiammation  of  the  epiphyses  of 
the  long  bones,  which  may  become  separated  from  the 
shafts. 

The  liver  and  spleen  are  often  enlarged,  and  the  child  soon 
presents  the  dull,  earthy,  anaemic  appearance  of  a  severe 
toxaemia. 

These  signs  usually  disappear  in  a  year  or  eighteen  months  ; 
the  later  phenomena  are  : — 

(a)  HutchinsoH's  Teeth.     The  permanent  central  upper 

incisors  are  peg-shaped,  being  broader  towards  the  gums 

than  at  their  free  edge,  and  possess  a  notch,  which  is  a 


74  MEDICAL  DIAGNOSIS 

large  segment  of  a  small  circle,  in  the  centre  of  their  cutting 
edges.     The  other  teeth  are  often  dwarfed  as  well. 

{b)  Interstitial  Keratitis  and  Disseminated  Choroiditis. 
These  usually  appear  about  puberty,  but  are  sometimes 
evident  about  the  ninth  or  tenth  year. 

(c)  Deafness.  This  is  most  likely  to  happen  between 
the  ages  of  fourteen  and  twenty-one. 

[d]  Chronic  synovitis,  especially  of  the  large  joints, 
such  as  the  knee,  as  well  as  periostitis  of  the  long  bones, 
are  other  phenomena  which  may  be  met  with  during 
adolescence. 

Both  gummata  and  lardaceous  disease  are  rare  in  con- 
genital syphilis. 

Diagnosis,  (i.)  The  Primary  Sore.  The  initial  appear- 
ance three  or  four  weeks  after  exposure  to  infection  is  im- 
portant, but  it  is  often  impossible  to  obtain  a  reliable 
history. 

The  syphilitic  chancre  is  nearly  always  single,  but  there 
maybe  two  or  three.  Further,  its  presence  may  be  masked 
by  an  herpetic  eruption  or  by  the  coexistence  of  soft  sores  ; 
the  typical  induration  is,  however,  met  with  in  no  other 
condition. 

Indolent  buboes  in  the  groin  form  corroborative  evidence. 

(ii.)  Secondary  Syjihilis.  If  this  is'  suspected,  evidence 
of  a  primary  clian(;re  must  be  carefully  sought  ;  for  the  rest 
the  clinical  diagnosis  must  depend  on  the  pleomorphic, 
symmetrical  character  of  the  rash,  the  coppery  stains  where 
the  rash  has  faded,  the  evidence  or  history  of  sore  throat, 
and  the  diffuse  glandular  enlargement.  A  scaly  rash 
on  the  palms  of  the  hands  and  soles  of  the  feet  is  said  to  be 
pathognomonic . 

(iii.)  Tertiary  Syphilis.  The  manifestations  of  tertiary 
syphilis  are  so  diverse  in  their  character  that  the  diagnosis 
may  well  be  impossible.  In  any  case  of  obscure  disease 
syphilis  must  be  suspected,  and  in  this  connection  it  is 
important  to  remember  that  no  station  in  life  is  immune, 
and  that  unfortunately  there  is  no  disease  about  which  it 
is  more  difficult  to  extract  a  truthful  history  from  the 
patient. 

In  the  case  of  women  it  is  doubly  difficult,  for  the  primary 


SPECIFIC    INFECTIVE   DISEASES  75 

lesion    may    well    have    been    overlooked    and    secondary 
manifestations  are  often  extremely  slight. 

Careful  inquiry  should  therefore  be  made  as  to  any  skin 
eruption  or  sore  throat,  any  loss  of  hair,  and  especially 
a  history  of  miscarriages  and  at  what  month  they  occurred, 
(iv.)  Congenital  Syphilis.  The  stigmata  of  congenital 
syphilis — namely,  the  stunted  appearance,  the  earthy  com- 
plexion, the  depressed  bridge  to  the  nose,  the  scars  round  the 
mouth,  the  bossed  skull,  the  hazy  cornese  of  interstitial 
keratitis,  and  the  Hutchinson's  teeth— present  a  sufficiently 
striking  picture. 

In  many  cases,  however,  the  majority  of  these  signs  are 
wanting — for  example,  the  rapid  onset  of  deafness  about  the 
age  of  puberty  may  be  the  only  manifestation.  In  such  cases 
Wassermann's  reaction  {vide  infra)  is  of  great  value,  though 
positive  reactions  are  not  obtained  in  quite  such  a  high/ 
percentage  of  congenital  cases  as  in  acquired  cases.  The 
Wassermami  reactions  of  the  parents  of  suspected  congenital 
syphilitis  may  afford  valuable  corroborative  evidence,  even 
if  the  patient  himself  gives  a  negative  reaction. 

Special  Methods  of  Diagnosis.  Until  recently  it  was 
often  impossible  to  establish  the  diagnosis  of  syphilis 
except  by  the  therapeutic  method — that  is  to  say,  until 
exhibition  of  antisyphilitic  treatment  had  cured  the 
disease  ;  but  nowadays  it  is  possible  to  diagnose  active 
s^-philis  in  any  stage  by  one  or  other  of  the  following 
methods  : — 

(a)  The  Ultra-Microscope.  By  this  means  it  is  possible 
to  demonstrate  the  Treponema  in  the  discharges  of  pri- 
mary and  secondary  lesions.  The  primary  chancre  and 
mucous  patches  are  particularly  favourable.  The  lesion 
is  kept  free  from  antiseptics  for  three  or  four  days  ;  it 
is  then  thoroughly  washed  with  plain  water,  and  dried  and 
finally  scraped  with  a  blunt  scapula  (an  ordinary  pen-nib 
is  useful  for  this  purpose).  The  first  discharge  is  carefully 
wiped  off,  when  in  a  few  seconds  a  bead  of  serum  will 
exude  from  the  excoriated  surface.  This  is  taken  on  a  plati- 
num loop  and  mixed  with  a  drop  of  distilled  water  on  a 
microscope  slide,  a  thin  cover-slip  is  super-imposed, 
and  the  preparation  is  promptly  examined  with  a  ^^^  inch 


7  b  MEDICAL  DIAGNOSIS 

immersion  lens  with  a  dark  ground  illumination.  The 
ultra-microscope  is  a  mechanism  of  prisms  which  can  be 
attached  to  an  ordinary  microscope,  the  result  is  that 
any  refractile  particle  is  thrown  into  strong  relief  against 
a  black  background.  A  drop  of  cedar-wood  oil  is  placed 
on  the  upper  surface  of  the  condenser  and  this  is  racked 
up  to  touch  the  under  surface  of  the  slide.  The  Treponema 
will  appear  as  a  silvery  filament  with  eight  or  ten  tight 
spirals  moving,  often  rapidly,  across  the  black  background. 
The  Spirochseta  refringens,  a  normal  inhabitant 
of  preputial  secretions,  may  by  accident  be  present  and 
must  not  be  mistaken  for  the  Treponema  ;  it  is  a  larger 
organism,  with  much  wider  and  more  irregular  spirals. 

(6)  Wassermann's  Reaction.  This  reaction  depends 
on  properties  of  the  blood  serum  of  syphilitic  patients. 
It  cannot  be  obtained  till  six  weeks  after  the  first  appear- 
ance of  the  primary  sore,  but  thereafter  it  persists  so 
long  as  there  is  active  syphilis. 

To  perform  the  reaction  it  is  necessary  to  procure 
the  following  : — 

(i.)  The  patient's  serum,  5  cc.  of  which  can  be  obtained 

by  veni-puncture  {vide  p.  157). 
(ii.)  An   extract   of    syphilitic   liver.      This   can   best 

be  obtained  from  a  syphilitic  foetus, 
(iii.)  Healthy  guinea-pig's  serum,  containing  a  known 

quantity  of  complement. 
(iv.)  The  blood   serum   of   an   animal,   say   a   rabbit, 
that  has  been  immunised  against  the  red  corpuscles 
of  some  other  animal,  say  a  sheep.    This  is  obtained 
by  injecting  the  rabbit  with  sheep's  corpuscles, 
whereby  a  body  is  elaborated  in  the  blood  serum 
of    the    rabbit    which    is    capable    of    destroying 
by  haemolysis  the  red  cells  of  a  sheep. 
(v.)  A  suspension  in  saline  of  washed  sheep's  corpuscles. 
Since  there  is  a  variable  amount  of  complement  present 
in  all  blood  serum,  it  is  necessary  to  remove  this    from 
the  patient's  serum  and  the  hsemolytic  rabbit's  serum. 
This  can  be  done  by  heating  to  57°  C.  for  two  hours. 

(i.),  (ii.)  and  (iii.)  are  now  added  together  and  incubated 
at   37"   C.   for  two  hours.     If  the  patient  is  syphilitic. 


.SPECTFTC   INFECTIVE   DISEASES  77 

his  blood  serum  contains  s^7)hilitic  antitoxins  ;  these  ■will 
unite  with,  the  sj^hilitic  toxins  in  the  liver  extract  by 
the  aid  of  the  complement  of  the  guinea-pig's  serum, 
and  in  so  doing  the  complement  will  be  fixed  and  rendered 
incapable  of  further  action. 

(iv.)  and  (v.)  are  now  mixed  together  and  added  to  the 
first  mixture,  the  whole  being  put  into  the  incubator 
at  37°  C.  for  half  an  hour  ;  but  the  haemolytic  power  of 
the  rabbit's  serum  for  the  sheep's  blood-cells  can  only 
be  exercised  in  the  presence  of  complement  :  therefore 
if  the  only  complement  present,  namely  that  of  the  guinea- 
pig  serum,  has  already  been  fixed  by  the  syphilitic  toxins 
and  anti-toxins,  there  will  now  be  no  liberation  of  haemo- 
globin from  the  sheep's  blood  corpuscles,  which  will 
settle  to  the  bottom  of  the  tube  leaving  clear  fluid  above. 
The  reaction  is  then  said  to  be  positive. 

If,  on  the  other  hand,  the  patient  is  not  syphilitic,  there 
will  be  no  syphilitic  antitoxins  in  his  blood  serum  ;   there- 
fore the  complement  in  the  guinea-pig's  serum  will  still 
be  free  to  enable  the  hsemolytic  action  of  the  rabbit's 
blood  on  the  sheep's  corpuscles  to  take  place.     As  a  result 
the  hsemoglobin  will  be  liberated  from  the  sheep's  cor- 
puscles and  the  contents  of  the  tube  will  assume  a  uniform 
pink  coloration.     The  reaction  is  then  said  to  be  negative. 
It  is  found  in  practice  that  it  is  not  necessary  to  use  an 
extract  of  syphilitic  liver,  equally  good  results  being  obtained 
from  the  use  of  an  alcoholic  extract  of  guinea-pig's  or  rabbit's 
heart.     It  is  possible  that  colloidal  change  is  at  the  bottom 
of  the  various  interactions  outlined  above. 

The  diagnostic  value  of  Wassermann's  reaction  cannot 
well  be  overestimated.  When  properly  pei'formed  with  con- 
trol tubes  of  known  syphilitic  and  known  healthy  serum  the 
margin  of  error  is  probably  less  than  ton  percent. ;  further, 
it  is  possible  togo.ugothe  success  of  the  treatment  employed 
by  the  rapidity  through  which  successive  Was.sermann  tests 
pass  through  stages  of  no  hrcmolysis,  slight  haemolysis,  and 
full  h.'cmoly.sis. 

The  reaction  is  present  in  congenital  sA'philis  and  also  in 
the  gi'eat  majority  of  cases  of  parasyphilitic  di.sease.  It 
must  be   mentioned,    however,    that    the   reaction   can   be 


78 


MEDICAL  DIAGNOSIS 


obtained  in  certain  other  diseases  which  are  due  to  protozoon 
infections,  such  as  yaw^s  and  sleeping-sickness,  and  also  during 
the  acute  stages  of  some  of  the  specific  infections,  such  as 
pneumonia  and  sometimes  in  scarlet  fever. 


XXI.  TETANUS. 

Definition.  A  specific  infective  disease  characterised  by 
tonic  spasms  of  the  muscles. 

Bacteriology.  The  causative  organism  (Bacillus  tetani) 
is  a  long,  slender  flagellated  rod,  one  end  of  which  is  often 
occupied  by  a  spherical  spore.  This  produces  the  character- 
istic "drum -stick" 
appearance.  The  bacillus 
is  slightly  motile  and 
grows  well  at  the  body 
temperature,  but  is 
anaerobic.  This  latter 
quality  makes  it  easier  for 
the  tetanus  bacilli  to  grow 
in  a  wound  which  is  also 
infected  with  some 
aerobic  organisms,  such 
as  the  Staphylococftus 
pyogenes,  which  use  up 
the  oxygen  in  the  neigh- 
bourhood. 

The  organism  stains  well  with  basic  aniline  dyes  and  is 
Gram-positive.  It  grows  on  ordinary  culture  media,  and  a 
stab  culture  on  gelatine  produces  what  is  known  as  the 
"  inverted  fir-tree  "  appearance. 

Tetanus  is  a  true  toxaemia,  the  baciUi  being  strictly 
localised  to  the  site  of  the  lesion.  The  toxins  manufactured 
by  the  bacilli  spread  by  the  blood-stream  and  eventually 
travel  upwards  to  the  central  nervous  system  along  the 
course  of  the  peripheral  nerves. 

The  natural  habitat  of  the  tetanus  bacillus  is  the  intestinal 
tract  of  herbivorous  animals  and  soil,  particularly  soil  that 
has  been  well  manured,  where  it  is  believed  to  pass  a  sapro- 
phytic stage  in  its  life  history. 


Fig.  20. — Bacillus  Tetani   showing  spore 
formation.     Magnification  /.   1000. 


SPECIFIC   INFF.CTIVE   DISEASES  79 

Incubation  Period.  Five  to  fifteen  days  (usually  ten  or 
twelve).  The  longer  the  incubation  period,  the  less  severe 
is  the  attack. 

Course.  The  first  symptom  is  stiffness  in  the  muscles  of 
the  neck,  though  sometimes  shivering  or  rigors  may  precede 
this  by  a  few  hours. 

The  stiffness  soon  involves  the  muscles  of  mastication, 
and  gradually  a  tonic  spasm  supervenes  in  the  affected  parts. 
The  eyebrows  are  raised  and  the  angles  of  the  mouth  drawn 
outwards,  thus  causing  the  characteristic  "  risus  sardonicus." 

The  spasm  soon  passes  to  the  other  muscles  of  the  body, 
the  back  muscles  being  particularl}-  involved,  so  that  a 
position  of  opisthotonos  is  likely  to  be  assumed. 

Although  the  muscidar  .spasm  never  relaxes  completely,  it 
is  liable  to  profound  exacerbations,  which  may  be  produced 
by  the  most  trifling  causes.  The  paroxysms  may  be  accom- 
panied by  extreme  pain,  and  the  patient  perspires  freely. 
As  the  disease  progresses  the  temperature  usually  rises 
(though  it  may  be  high  from  the  start),  and  before  death, 
which  usually  jccurs  within  four  days  in  those  acute  cases 
which  have  a  short  incubation  period,  the  thermometer  will 
not  infrequently  register  108°  or  109°.  Death  may  be  due 
to  heart  failure,  asphyxia,  or  exhaustion. 

Varieties.  In  addition  to  the  ordinary  form  described 
above  the  following  varieties  may  be  mentioned  : — 

(i.)  Chronic  Tetanus.  This  variety  is  likely  to  have  a 
long  incubation  period  (ten  to  fourteen  days).  The  spasms 
may  be  confined  to  the  neck  and  jaws  ;  there  is  little  or  no 
pyrexia,  and  the  course  may  be  protracted  foi-  several  weeks 
with  intervals  of  com])arative  comfort.  Recovery  is 
usual. 

(ii.)  Cephalic  Tetanus.  This  variety  usually  follows  a 
lesion  to  the  scalp.  The  chief  features  will  hv  facial  paralysis 
and  pharyngeal  spasm.     {Vide  also  Hydrophobia.) 

(iii.)  Tetanus  Neonatorum  or  Tetanus  of  Neuiy-horn 
Infants.     This  is  due  to  infection  of  the  umbilicus. 

(iv.)  Idiopathic  Tetanus.  This  almost  certainly  does  not 
exist  ;  cases  so  described  were  probably  those  in  which  the 
abrasion  through  which  the  infection  was  acquired  was  so 
small  as  to  escape  notice. 


80  MEDICAL   DTAGNOSTS 

Diagnosis.  The  history  of  a  wound,  particularly  of  a 
septic  wound,  in  the  preceding  fortnight  is  important,  but 
it  must  be  remembered  that  the  site  of  infection  may  be 
completely  healed  before  the  onset  of  symptoms. 

Where  there  is  an  open  wound  the  organism  may  some- 
times be  seen  in  film  preparations  of  the  discharge.  If  such 
examination  is  inconclusive,  it  is  advisable  to  inoculate  a 
deep  glucose-gelatine  tube  with  the  suspected  material. 
Incubation  of  such  a  tube  for  forty-eight  hours  will  often 
show  spore-bearing  tetanus  bacilli  mixed  with  the  other 
organisms.  Again,  mice  or  guinea-pigs  may  be  inoculated 
subcutaneously  with  the  material  from  the  wound,  when  if 
tetanus  bacilli  are  present  the  animal  will  shortly  manifest 
tetanic  symptoms. 

The  onset  of  stiffness  and  spasm  in  the  muscles  of  the  neck 
and  jaws,  with  the  subsequent  course  of  the  disease,  will 
usually  leave  no  doubt  as  to  the  correctness  of  the  diagnosis. 

It  is,  however,  necessary  to  exclude  the  following  con- 
ditions : — 

(i.)  Trismus  from  other  causes  :■ — ■ 

(a)  Hysteria.     Hysterical  trismus  is  not  accompanied 

by  rigidity  of  the  neck,  and  though  there  may  be  an 

irregular  opisthotonos,  this  latter  is  transient  and  only 

seen  in   conjunction  with   a  definite   hysterical   seizure. 

There  is  no  true  risus  sardonicus. 

(6)  Dental  irritation,  such  as   impacted  wisdom  tooth, 

etc.     Here  there  is  never  a  risus  sardonicus,  and  a  little 

investigation  will  reveal  the  tooth  which  is  causing  the 

trouble. 

(c)  Acute,  or,  more   commonly,  Chronic  meningitis  or 

Intracranial  turnottr,  causing  irritation  of  the  motor  part 

of   the   fifth   nerve.     The   other   signs   of   meningitis   or 

cranial  tumour  will  be  present. 

(ii.)  Strychnine  Poisoning.  Here  there  is  a  sudden  onset ; 
the  spasm  affects  the  whole  body  and  is  never  seen  first  in 
the  neck  and  jaws,  while  between  the  convulsive  attacks 
there  is  complete  relaxation  of  the  muscles^, 

(iii.)    Hydrophobia  {vide  p.  29). 

(iv.)  Tetany.  Tetany  is  seen  in  rickety  children  and 
nursing  women  ;  it  is  usually  limited  to  the  hands  and  feet, 


SPECIFIC   IXEECTIVE   DISEASES  81 

which   are   in   a  position   of   adduction  and   flexor   spasm. 
Trismus  is  of  extremely  rare  occurrence. 


XXII.  TUBERCULOSIS. 

Definition.  A  specific  infective  disease,  dependent  on  the 
presence  of  the  tubercle  bacillus  in  one  or  more  organs  of  the 
body  and  of  the  circulation  in  the  blood-stream  of  the  toxins 
elaborated  in  the  tuberculous  lesion. 

Bacteriology.  The  specific  micro-organism  is  a  slender 
non-motile  rod-shaped  bacillus  from  3  to  4  ^a  in  length  ;  it  is 
often  slightly  curved,  and  when  stained  appears  to  be  beaded. 
It  can  be  cultivated  at  a  temperature  of  37°  C.  on  glycerine 
agar,  glycerinated  potato,  and  other  kindred  media  /in 
the  form  of  yellowish-brown  crusts,  but  it  does  not  grow 
readily  outside  the  body,  and  there  is  usually  considerable 
difficulty  in  obtaining  cultures  from  tuberculous  sputum  or 
the  discharges  from  other  tuberculous  lesions  in  man.  For 
purposes  of  cultivation  some  of  the  tuberculous  material 
should  be  injected  subcutaneously  into  a  guinea-pig.  In 
six  weeks  the  animal  will  be  in  a  condition  of  tuberculous 
septicaemia  with  profuse  visceral  tuberculosis.  The  spleen 
is  especially  involved  and  cultures  can  readily  be  made  from 
the  lesions  in  this  organ. 

Owing  to  the  presence  of  a  waxy  material  in  the  sheath 
of  the  tubercle  bacillus,  powerful  and  prolonged  staining  is 
necessary  for  its  demonstration.  For  this  purpose  advantage 
is  taken  of  the  fact  that  the  tubercle  bacillus,  in  common 
with  the  leprosy  bacillus,  the  bacillus  of  smegma,  the 
butter  bacillus,  and  the  timothy-grass  bacillus,  is  acid  and 
alcohol  fast — that  is  to  say,  that  the  colour  is  not  lost  if  tlu' 
preparation  is  dipped  in  acid  or  alcohol  after  first  being 
stained  with  a  strong  solution  of  carbol-fuchsin. 

It  is  most  frequently  necessary  to  demonstrate  the  bacillus 
in  sputum  or  urine.  For  this  purpose  the  following  technique 
may  be  adopted  :— 

The  sputum  is  poured  into  a  shallow  dish  and  a  purulent 
particle  is  picked  out  with  clean  forceps  and  placed  on  a 
slide.     This  is  then  spread  in  a  fairly  thin  uniform  film  either 

M.D.  (5 


82  MEDICAL  DIAGNOSIS 

by  rubbing  with  a  needle  or  by  flattening  out  with  another 
shde.  In  the  case  of  urine  the  specimen  should  be  obtained 
by  catheterisation.  It  is  then  centrifugalised  and  a  small 
portion  of  the  deposit  is  spread  as  a  film  on  the  surface  of  a 
slide.  In  both  cases  the  film  is  dried  in  the  air  and  fixed  by 
passing  two  or  three  times  through  the  flame  of  a  Bunsen 
burner  or  spirit  lamp.  Some  filtered  Ziehl-Neelson  carbol- 
fuchsin  solution  is  now  heated  to  boiling  point  in  a  test-tube 
and  poured  on  to  the  slides.  At  the  end  of  three  minutes  the 
carbol-fuchsin  is  washed  off  and  the  slides  are  immersed  for 
a  few  seconds  in  thirty-three  per  cent,  nitric  acid  and  again 
washed  in  water.  This  process  is  repeated  until  there  is 
just  no  return  of  pink  coloration  when  the  nitric  acid  is 
washed  oft'.  A  half  per  cent,  aqueous  solution  of  methylene 
blue  is  now  added  for  twenty  seconds  ;  the  preparation  is 
then  washed  and  dried  and  is  ready  for  examination.  If 
permanent  preparations  are  desired,  a  cover-slip  may  be 
affixed  with  Canada  balsam  in  the  usual  manner,  but  for 
ordinary  purposes  a  drop  of  cedar-wood  oil  may  be  placed 
directly  on  the  film  and  a  ^._^  inch  objective  used  in  the 
ordinary  way.  When  stained  in  this  manner  tubercle  baciUi 
are  seen  as  bright-red  rods,  while  any  other  structures 
(organisms,  cells,  fibrin,  etc.)  that  may  be  present  are 
coloured  a  pale  blue.* 

There  are  three  varieties  of  tubercle  bacilli — avian,  bovine, 
and  human.  It  is,  hoAvever,  possible  that  the  differences  in 
these  varieties  depend  on  the  different  environment  and  that 
a  few  generations  of  growth  may  be  sufficient  to  convert 
one  form  into  another.     Certainly  there  is  evidence  that 

*  \'arious  sedimentatiuii  tests  have  been  devised  for  the  demonstration  of 
tubercle  bacilli  in  the  sputum.  The  best  of  these  is  the  method  of  Ellerman 
an.l  Erlandsen,  which  is  conducted  as  follows  : 

(i.)  One  volume  of  sputum  is  mixed  with  half  a  volume  of  0'6  per  cent, 
sodium  carbonate  solution  in  a  corked  glass,  and  placed  in  the  incubator 
at  37'^  C  for  twenty-four  hours, 
(ii.)  The  greater  part  of  the  supernatant  Huid  is  then  poured  off,  and  the 

remainder  is  centrif  uged. 
(iii.)  To  the  deposit  so  obtamed,  four  volumes  of  0'25  per  cent,  sodium  hydrate 

solution  are  added,  and  after  thorough  mixing,  the  fluid  is  boiled, 
(iv.)  Ihe  resulting  solution  is  again  centrifuged. 
(v.)  Films  are  made  from  the  deposit  obtained,  and  stained   in  the  usual 

manner. 
It  is  probable  that  a  slightly-  higher  .Percentage  of  positive  residts  is  obtained 
with  sputa  examined  by  this  methotl  as  compared  w  ith  the  more  usual  method 
described  in  the  text. 


^' 


» 


H' 


y,^ 


<» 


hiJ^       % 


■^-, 


0 


f    %- 


::/^ 


-^  ^T 


/^ 


Fig  21.— 'Iiibcrcle  Bacilli  in  I'linc.     Ziehl-xNei'Ison  .Method 
.MayniHcation   -    lOWt. 


SPECIFIC  INFECTIVE  DISEASES 


83 


liuiiian  beings,  and  especially  children,  are  susceptible  to 
infection  from  bovine  tubercle  bacilli. 

Since  tuberculous  lesions  may  occur  in  any  organ  of  the 
body,  it  will  be  convenient  to  consider  separately  the  effects 
produced  in  the  different  anatomical  regions. 


Fig.  22. —Chart  to  show  inverse 
t^^pe  of  PjTcxia  in  some  ca.ses 
of  Miliary  Tuberculosis. 


I.  ACUTE   MILIARY   TUBERCULOSIS. 

This  disease  depends  on  the  introduction  into  the  blood- 
stream of  overwhelming  numbers  of  tubercle  bacilli  ;  the 
result  is  the  formation  of  countless  so-caUed  miliary  tubercles 
widely  diffused^throughout  the 
viscera.  Each  tubercle  i  s 
deposited  on  the  walls  of  the 
smaller  arteries.  They  are 
particularly  well  seen  in  the 
pleiu'se,  lungs,  liver,  spleen, 
and  kichieys  and  in  the  pia 
mater  at  the  base  of  the  brain. 
It  is  inconceivable  that  such 
enormous  numbers  of  bacilli 
should  enter  the  blood-stream 
except  from  a  pre  -  existing 
tuberculous  lesion.  The  most 
frequent  primary  lesions  are  tuberculous  glands,  particularly 
bronchial  glands,  which  may  ulcerate  into  a  vein ;  or  fibro- 
caseous  disease  of  the  lungs.  Possibly  the  ulceration  of  a 
tuberculous  deposit  in  the  intima  of  a  blood-vessel  may 
sometimes  be  the  primary  focus.  It  is  obvious  that  the 
miliary  tubercles  are  too  small  per  se  to  give  rise  to  any 
physical  signs,  and  in  the  case  of  a  primary  glandular  lesion 
this,  too,  may  not  be  susceptible  of  clinical  recognition. 
So  that  in  many  cases  of  acute  miliary  tuberculosis  the 
diagnosis  must  depend  largely  upon  the  signs  and  symptoms 
of  the  profound  toxaemia  which  is  produced. 

In  a  considerable  proportion  of  cases,  however,  the  basal 
meninges  are  affected,  and  it  is  not  too  much  to  say  that 
general  tuberculosis  is  often  not  diagnosed  until  the  charac- 
teristic signs  of  tuberculous  meningitis  make  their  appear- 
ance.    It  must  further  be  borne  in  mind  tliat   in  this,  the 

li — 2 


84  MEDICAL  DIAGNOSIS 

most  acute  form  of  tubercular  infection,  the  protective 
mechanism  of  the  tissues  appears  to  be  completely  paralysed, 
and  this  may  account  for  the  fact  that  the  various  diagnostic 
reactions — e.g.,  von  Pirquet,  Calmette,  the  injection  of 
tuberculin,  and  the  estimation  of  the  opsonic  index — so  often 
give  a  negative  result  in  such  cases. 

Clinically  it  is  possible  to  differentiate  three  forms  of  acute 
miliary  tuberculosis. 

(a)  The  Typhoid  Form.  The  onset  is  usually  gradual, 
with  rising  temperature  and  a  rapid  feeble  pulse.  There  is 
ea:ly  delirium  and  a  definitely  accelerated  respiration  rate, 
whilst  the  patient  soon  passes  into  a  condition  of  coma. 
The  temperature  is  strikingly  irregular  ;  often  it  is  of  the 
inverse  type — that  is  to  say,  it  rises  in  the  morning  and  falls 
A\  the  evening. 

In  rare  cases  there  may  be  abdominal  distension  and 
diarrhoea  ;  constipation,  however,  is  the  rule.  The  spleen 
is  often  enlarged  and  albuminuria  may  be  present. 

The  diagnosis  of  this  form  of  tuberculosis  from  enteric 
fever  may  be  extremely  difficult.  The  following  table 
shows  the  essential  differences  : — 

Miliary    Tuberculosis    {Typhoid  Enteric  Fever 

Form). 

Epistaxis  rare.  Epistaxis  common. 

Pulse  rapid.  Pulse    slow    in    proportion    to 

temperature. 

Spleen  less  constantly  enlarged  Spleen  enlarged  early. 

and  at  a  later  date. 

Widal  negative  throughout.  Widal  positive  after  first  week. 

Herpes  fairly  common.  Herpes  rare. 

Eash     (if     any)     an     irregular  Rash  papular  and  in  crops. 

erythema. 

Moderate  leucocytosis   with  ex-  Leucopenia. 

cess  of  lymphocytes. 

Possible      evidence      of      local  Probable    presence    of    Bacillus 

tuberculosis,    e.g.,    lungs     or  Typhosus   in    the    blood    and 

choroid.  urine. 

(6)  The  Pulmonary  Type.  This  form  is  most  likety  to 
occur  as  a  sequel  of  chronic  pulmonary  tuberculosis.  In 
children  it  not  uncommonly  foUows  measles  or  whooping- 


SPECIFIC   INFECTIVE   DISEASES 


85 


cough.  Under  these  circumstances  it  is  accompanied  by 
a  true  tuberculous  broncho-pneumonia,  and  it  is  to  this 
latter  condition  that  the  physical  signs  are  to  be  attributed. 
There  is  always  cough,  with  muco-purulent  expectoration, 
very  marked  cyanosis,  extreme  rapidity  of  respiration,  and 
dyspnoea.  Percussion  will  reveal  a  uniform  impairment 
of  resonance  at  the  bases  or  scattered  dull  areas  due  to 
broncho-pneumonic  consolidation,  or,  what  is  perhaps 
equally  significant,  widespread  areas  of  hyper-resonance  due 
to  a  more  or  less  acute  compensatory  emphysema.  With 
the  stethoscope  there  will  be  heard  fine  crepitant  rfiles, 
widely   distributed,    while    tubular   breathing   from   either 


i 

r 
m' 

105' 
10*' 
103° 
lOi' 
101' 
100° 
93° 
98' 

M    E 

M   E 

M   E 

M  E 

M    E 

M  E 

M  E 

M  E 

M   E 

ME 

M   E 

M  E 

M  E 

ME 

M  E 

[■ 

A 

A 

..A. 

A 

\ 

A 

/ 

/ 

^' 

J 

V 

V     ' 

Av 

'  V 

•A 

■  f, 

r 

,/ 

Y 

A 

s/' 

K 

J: 

:  1 

... 

--- 

... 

... 

... 

... 

--• 

... 

■J^ 

•"• 

~T^ 

Fig.  23. — Temperature  Chart  showing  continuous  t\'pe  of 
P3Texia  in  certain  cases  of  Miliary  Tuberculosis. 

consolidation  or  coUapse  is  relatively  common.  The  sputum 
may  contain  tubercle  bacilli,  but  this  is  by  no  means  in- 
variable. The  spleen  is  usually  enlarged.  The  diagnosis  will 
be  seen  therefore  to  depend  largely  upon  the  occurrence  of 
cyanosis  and  dyspnoea,  with  the  signs  of  capillary  bronchitis, 
or  even  broncho-pneumonia,  occurring  in  a  patient  who  is 
known  to  have  fibro-caseous  pulmonary  tuberculosis,  or 
in  the  case  of  a  child  to  have  recently  suffered  from  measles 
or  whoo])ing-cough. 

(c)  The  Meningeal  Form  (Tuberculous  Meningitis).  Both 
the  typhoid  and  the  pulmonary  forms  maybe  accompanied 
by  tuberculous  meningitis,  a  condition  which  is  only  met 
with  in  cases  of  a  generalised  tuberculosis  ;  but  frecpiently 
there  are  no  symptoms  by  which  the  general  infection  can 
be  diagnosed  until  the  meninges  have  l)ecome  involved. 

Tuberculous  meningitis  is  much  more  common  in  children 


86 


MEDICAL  DIAGNOSIS 


than  in  adults,  though  it  is  rare  in  the  first  year  of  hfe.  The 
primary  focus  is  frequently  glandular,  the  most  common 
glands  being  the  infra-tracheal,  bronchial,  or  mesenteric. 
The  inflammation  affects  the  base  of  the  brain,  the  miliary 
tubercles  being  deposited  along  the  course  of  the  blood- 


1 

1 

1 

106' 

ids' 

ICH° 
103° 
102" 
101° 
100° 
99° 
98° 

06° 
^.9S° 
1*0 
130 
120 

no 

100 
90 
SO 
70 
BO 

■?so 

55 
45 
35 
25 

M    E 

M   E 

M   E 

M   £ 

M  e 

M  E 

M  E     M  E 

M   E 

M  E 

M  E 

M  E 

M  E 

ME 

/\ 

A 

A 

A 

A 

A 

/\ 

A 

/ 

,A 

/ 

\ 

n 

/\ 

/ 

h 

A 

)A 

/; 

.    \ 

/: 

■■' 

y 

\: 

r- 

/ 

/' 

/ 

/  ■ 

V: 

V\ 

V 

■\ 

... 

... 

.. 

.. 

... 

--■ 

-^• 

... 

... 

■  ^H 

--• 

.^. 

^ 

"T" 

• 

\  . 

\ 

• 

; 

^ 

■    J 

^ 

■'a 

,/ 

/- 

./ 

f 

/\ 

■■/^ 

■A 

■f 

r 

-y' 

M 

^  \ 

[/. 

k/ 

V 

^ 

v" 

4 

.qi. 

" 

3a 

a*c 

"•■ 

•q>. 

: 

... 

-r- 

-«- 

«»■ 

'*" 

■  «M 

; 

T^ 

-^ 

" 

--^ 

*rS 

^~~ 

S: 

^^ 

;'*^^ 

Fig.  24. 


Chart  from  a  case  of  generalised  Tuberculosis 
with  Tuberculous  Meningitis. 


vessels  in  the  pia  mater  of  the  inter-peduncular  space  and  the 
Sylvian  fissures. 

Course.  Commonly  there  is  malaise  and  general  debility 
for  several  weeks.  Starting  from  the  onset  of  definite 
symptoms,  three  somewhat  indefinite  stages  may  be  recog- 
nised. 

First,  the  stage  of  irritation.  This  stage  may  be  ushered 
in  by  convulsions,  foUowed  by  severe  headache,  vomiting, 
and  pyrexia.     The  child  is  usually  constipated  and  gives 


SPECIFIC   INFECTIVE   DISEASES  87 

frequent  utterance  to  the  short,  sharp  hydrocephalic  cry  ; 
the  pupils  are  contracted,  the  pulse  is  slow  and  irregular, 
but  there  is  no  rapidity  of  respiration,  unless  there  is  a 
coincident  pulmonary  lesion.  Kernig's  sign  (see  p.  6)  is 
often  present. 

Secondly,  the  stage  of  depression.  This  stage  depends 
upon  the  gradual  increase  in  intra -cranial  tension.  The 
temperature  is  lower,  the  headache  is  less  marked,  the  child 
lies  quiet  and  appears  to  be  drowsy  ;  the  vomiting  may 
cease,  but  the  neck  is  stiff  and  the  head  tends  to  be  slightly 
retracted,  the  fontanelle  bulges  if  the  child  is  young  enough, 
the  abdomen  is  retracted,  and  commonly  there  is  a  con- 
vergent strabismus.  The  irregularity  of  the  pulse  persists, 
and  the  drowsiness  is  really  the  onset  of  coma. 

Thirdly,  the  stage  of  paralysis  or  coma.  In  this  stage 
the  child  is  persistently  unconscious  and  cannot  be  roused. 
Convulsions  are  common,  strabismus  is  more  marked,  and 
the  pupils  are  dilated  and  often  unequal.  The  pulse 
becomes  rapid,  but  the  temperature  is  strikingly  variable  ; 
it  may  be  sub -normal  or  it  may  be  high  throughout, 
Avhilst  just  before  death  there  is  often  hyperpyrexia. 

Optic  neuritis  is  said  to  be  present  before  the  close  in 
20  per  cent,  of  all  cases,  but  this  is  perhaps  a  rather  high 
estimate.  Choroidal  tubercles  may  occasionally  be  dis- 
covered. It  is  extremely  rare  for  life  to  be  prolonged  for 
more  than  four  weeks  from  the  onset  of  symptoms. 

Although  individual  cases  show  great  variability  in  their 
course,  the  diagnosis  of  tuberculous  meningitis  is  not  diffi- 
cult. The  slow  and  irregular  pulse,  the  headache,  the 
vomiting,  the  ocular  phenomena  as  described  above,  and  the 
stiffness  of  the  neck  are  all  important  points.  If  any  doubt 
exists  lumbar  puncture  should  be  performed.  The  cerebro- 
spinal fluid  is  under  tension  and  escapes  with  a  spurt  ;  it  is 
clear,  it  is  sterile,  and  it  contains  an  excessive  number  of 
h/ttiphori/tes.  Further,  its  power  of  reducing  copper  is 
diminished  or  absent.  In  very  exceptional  cases  tubercle 
bacilli  may  be  present. 

Tuberculous  m(Miingitis  must  not  be  mistaken  for  cerebro- 
spinal nieningitis  {ride  p.  6). 


88  MEDICAL   DIAGNOSIS 

II.    TUBERCULOSIS   OF   THE   LARYNX. 

With  hardly  an  exception  this  is  a  late  manifestation  in 
the  course  of  pulmonary  tuberculosis  ;  a  few  cases  of 
primary  disease  of  tlie  larynx  are  on  record. 

The  tubercles  are  formed  in  the  sub -epithelial  layer  of 
the  mucosa.  Their  most  frequent  situations  are  the  true 
and  false  vocal  cords,  the  epiglottis,  and  the  inter -arytenoid 
folds. 

Diagnosis.  The  principal  symptoms  are  hoarseness  or 
aphonia  and  an  irritating  cough.  When  ulceration  is  present 
there  is  both  difficulty  and  pain  in  swallowing.  If  the  vocal 
cords  are  extensively  involved  the  cough  may  become 
altered  in  character. 

The  laryngoscope  is  necessary  to  establish  the  diagnosis. 
The  mucous  membrane,  at  first  pale,  becomes  thickened 
with  inflammatory  exudation,  and  when  ulceration  is  present 
the  diseased  parts  present  a  worm-eaten  appearance.  The 
individual  ulcers  are  irregular  and  shallow  with  grey  bases. 
The  cords  are  often  fixed,  either  by  infiltration  or  by  paralysis 
of  the  recurrent  laryngeal  nerve.  When  the  fixation  is 
due  to  paralysis  the  palsy  is  likely  to  be  of  the  abductor 
type.  The  paralysis  is  not  due  to  the  laryngeal  tuber- 
culosis, but  to  some  involvement  of  the  nerve  lower  down. 
The  right  nerve  is  most  commonly  affected,  and  this  is 
thought  to  be  due  to  its  involvement  in  pleuritic  thickening 
at  the  apex  of  the  right  lung. 

Paralysis  of  the  left  nerve  may  sometimes  be  accounted 
for  by  pressure  of  enlarged  glands  at  the  root  of  the  left 
lung. 

Differential  Diagnosis,  (a)  Chronic  Simple  Laryngitis. 
Dysphagia  is  absent,  and  the  laryngoscope  shows  swollen 
and  injected  mucous  membrane,  but  no  ulceration. 

{b)  Syphilitic  Laryngitis.  Secondary  syphilis  may  pro- 
duce symmetrical  superficial,  serpiginous,  whitish  ulcers  on 
the  cords  or  ventricular  bands  ;   there  is  no  dysphagia. 

Tertiary  syphilis  may  produce  diffuse  gummatous  inflam- 
mation going  on  to  deep  ulceration  and  healing  in  tight 
fibrous  bands.  Gummatous  deposits  are  perhaps  most 
common  on  the  base  of  the  epiglottis.    There  is  no  dysphagia, 


SPECIFIC   mFECTIVE   DISEASES  89 

but  the  voice  is  very  thick  and  husky.  Complete  aphonia 
is  rare. 

(c)  Carcinoma  of  Larynx.  This  is  rare  before  the  age  of 
forty  and  is  six  times  commoner  in  men  than  women.  In 
carcinoma  starting  within  the  larynx  hoarseness  slowly 
increasing  in  severity  may  be  the  only  symptom  for  months. 
\Vith  the  laryngoscope  the  growth  appears  as  a  small 
circumscribed  thickening,  with  a  broad  base  and  often  N\'ith 
an  excoriated  surface.  Sooner  or  later  deep  ulceration  will 
occur  and  the  base  of  the  ulcer  is  likely  to  present  a  nodular 
appearance. 

Carcinoma  causes  early  and  extreme  dysphagia  ;  pain  is 
more  or  less  constant,  and  is  often  referred  to  the  ear  and 
occiput.  In  tuberculous  laryngitis  pain  is  usually  absent 
except  on  swallowing,  talking,  or  coughing. 

Where  there  is  any  doubt  some  of  the  secretion  from /the 
affected  part  should  be  examined  microscopically  for  tubercle 
bacilli,  or  a  small  piece  of  an  ulcer  may  be  excised  for 
histological   examination. 

III.   TUBERCULOSIS   OF    THE   LUNGS. 

Pulmonary  tuberculosis  is  met  with  in  four  varieties  : — 

{a)  Acute  lobar-pneumonic  tuberculosis. 

(6)  Acute  broncho-pneumonic  tuberculosis. 

(c)  Fibro-caseous  tuberculosis. 

{d)  Fibroid  tuberculosis. 
{a)  Acute  Lobar-pneumonic  Tuberculosis.  This  consists 
of  the  sudden  invasion  of  an  entire  lobe  or  even  an  entire 
lung  by  th"  tubercle  bacillus  ;  the  residt  is  a  massive  inflam- 
mation ill  all  respects  comparable  with  that  of  lobar  pneu- 
monia due  to  the  pneumococcus. 

'i'he  onset  with  rigor,  pain  in  the  side  and  cough,  as  well  as 
the  ])liysical  signs  of  consolidation,  make  the  diagno.sis 
from  ])neum')eoeca]  lol)ar  ])neumonia  ini])ossil)lc  iti  tlic  earlier 
stages.  A  })revious  liistory  of  pulmoruiry  tuberculosis  is, 
however,  suggestive,  and  in  a  considerable  proportion  of  cases 
the  pulse-rate  is  not  so  accelerated  as  in  ordinary  ])neunionia  ; 
consequently  pneumonia  with  a  pulsc-ratc  below  a  liundied 
should  suggest  the  possibility  of  tuberculosis.     Ordinarily 


90  MEDICAL   DIAGNOSIS 

the  true  nature  of  the  malady  is  not  suspected  until  in 
place  of  the  expected  crisis  between  the  seventh  and  the 
tenth  days  the  temperature  tends  to  assume  a  more  remit  - 
tent  character  and  the  sputum  becomes  muco-purulent  and 
green.  By  the  end  of  the  second  week  tubercle  bacilli  and 
elastic  tissue  may  be  present  in  the  sputum,  and  during  the 
third  week  there  are  likely  to  be  the  physical  signs  of  soften- 
ing and  cavity  formatixon.  A  number  of  patients,  especially 
children,  recover  with  cicatricial  fibrosis  and  contraction  of 
the  affected  lobe.  Possibly  in  a  larger  proportion  of  cases 
the  patient  dies  of  cachexia  and  exhaustion  at  the  end  of 
eight  or  nine  weeks.  Death  may,  however,  take  place 
during  the  first  week  from  profound  toxaemia.  The  differen- 
tial diagnosis  between  tuberculous  and  pneumococcal 
lobar  pneumonia  will  depend  upon  the  absence  of  crisis, 
the  more  remittent  temperature,  the  tendency  to  a  less  rapid 
rate  of  respiration  and  slower  pulse-rate,  the  liability  to 
perspiration,  and  lastly  upon  careful  and  repeated  examina- 
tions of  the  sputum  for  tubercle  bacilli  {vide  also  p.  81). 

(6)  Acute  Broncho-pneumonic  Tuberculosis.  This  variety 
is  more  common  than  the  lobar  form  :  it  is  of  frequent  occiu^- 
rence  in  children  and  also  as  a  terminal  event  in  fibro-caseous 
pulmonary  tuberculosis.  It  is  rarely  primary,  being  com- 
monly produced  by  ulceration  into  a  bronchus  of  a  tuber- 
culous gland,  or  as  a  sequel  of  measles  and  whooping-cough. 
Like  the  other  varieties  of  broncho-pneumonia,  the  onset 
tends  to  be  gradual  rather  than  acute.  The  physical  signs 
are  those  of  broncho-pneumonia,  fine  rales  of  capillary  bron- 
chitis, and  often  dull  areas  of  varying  size,  over  which  tubular 
breathing  may  be  present.  Tubercle  bacilli  and  elastic 
tissue  may  be  discovered  in  the  sputum,  which  is  usually 
profuse,  muco-purulent,  and  green.  Death  as  a  rule  occurs 
in  a  few  weeks,  though  in  very  exceptional  cases,  especially 
if  the  disease  happens  to  have  been  limited  to  one  lung, 
chronic  fibroid  disease  may  result.  The  relative  frequency 
with  which  tuberculous  broncho -pneumonia  may  be  found 
associated  with  generalised  tuberculosis  has  been  indicated 
in  the  discussion  of  the  latter  {vide  "  General  Tuberculosis, 
Pulmonary  Form,"  p.  84).  It  must  be  understood,  however, 
that  though  the  two  conditions  may  well  arise  from  the  same 


SPF.CIFIC   INFECTIVE   DISEASES  91 

primary  lesion  {e.g.,  a  caseous  bronchial  gland),  nevertheless 
their  distribution  is  essentially  different,  the  one  being 
conveyed  by  the  blood-stream,  the  other  by  the  lymphatics 
and  air  passages. 

(c)  Fibro-caseous  Tuberculosis.  This  is  by  far  the 
commonest  variety  of  pulmonary  tuberculosis.  It  is  most 
commonly  met  with  between  the  ages  of  15  and  25,  while 
after  the  age  of  35  the  liability  to  infection  seems  to  be 
definitely  diminished. 

Anatomy.  The  apices  of  the  lungs  are  first  affected  in 
the  majority  of  cases,  and  the  right  lung  is  more  liable 
than  the  left.  The  primary  lesion  is  usually  about  1 J  inches 
from  the  extreme  apex  and  nearer  the  back  than  the 
front,  a  fact  which  shows  the  necessity  of  examining  the 
back  of  the  lungs.  The  infection  .spreads  downwards,  both 
by  direct  extension  and  by  the  formation  of  small 'out- 
lying tubercles  conveyed  from  the  primary  focus  by  the 
lymph -stream.  As  the  disease  progresses  further  foci  are 
formed  by  the  aspiration  of  tuberculous  material  into  healthy 
bronchioles.  After  infection  of  the  right  upper  lobe  secon- 
dary infiltration  is  likely  to  take  place  at  the  apex  of  the 
right  \o\\VY  lobe,  and  then  at  the  apex  of  the  left 
upper  lobe,  and  conversely  should  the  primary  lesion  be 
on  the  left  side.  Wherever  the  primary  site,  the  infection 
starts  with  the  formation  of  one  or  more  hi.stological  tuber- 
cles, round  which  there  is  a  circumscribed  area  of  reactionary 
inflammation  and  consolidation  comparable  to  pneumonia. 
There  is  an  attempt  on  the  part  of  nature  to  shut  off  the 
diseased  area  by  the  protective  formation  of  fibrous  tissue, 
and  since  the  "  tubercle  ''  is  essentially  avascular  there  is 
a  tendency  for  softening  and  necrosis  to  occur  in  its  centre. 
It  will  thus  be  seen  that  fiom  the  very  outset  of  the  disease 
there  is  a  perpetual  warfare  between  the  tendency  of  the 
tuberculous  process  to  spread  peripherally,  and  the  attempt 
of  the  protective  mechanism  of  the  body  to  limit  the  de- 
stiuotive  process  by  the  intei-position  of  barriers  of  fibrous 
tissue. 

The  chronicity  of  an  individual  case  depends  in  a  great 
measure  on  which  of  these  two  processes  gains  the  u])perhand. 
In  some  cases  the  tuberculous  focus  is  shut   off  almost   at 


92  MEDICAL   DIAGNOSIS 

its  commencement,  in  others  the  disease  progresses  until  a 
bronchus  is  involved  of  sufficient  calibre  to  permit  the  evacua- 
tion of  the  necrotic  jnaterial  in  the  centre  of  the  lesion  ; 
in  this  manner  the  formation  of  a  cavity  takes  place. 
Stagnation  of  the  secretion  in  the  vomica  favours  secondary 
infection  with  other  organisms,  and  it  is  to  the  presence  of 
pneumococci  strepto-  and  staphylo -cocci  and  other  organ- 
isms in  the  more  advanced  cases  of  fibro-caseous  disease 
that  many  of  the  objective  symptoms  are  to  be  attributed. 

Diagnosis.  (1)  History.  Though  the  possibility  of  direct 
hereditary  transmission  may  be  neglected,  a  history  of 
existing  disease  in  the  parents  or  brothers  and  sisters  is  of 
importance  because  parents  are  likely  to  infect  their  children, 
and  the  house  where  tuberculous  patients  live  will  become 
infective  unless  the  most  scrupulous  precautions  be  observed. 

(2)  Symptoms.  The  onset  is  usually  gradual,  and  the 
early  symptoms  are  debility,  easy  fatigue  and  loss  of  appetite 
extending  over  weeks  or  months.  Progressive  loss  of  iveight 
is  the  rule.  Not  infrequently  the  patient  will  seek  advice 
because  of  dyspepsia  or  anaemia.  This  mode  of  onset  is 
perhaps  more  common  in  women,  who  are  also  likely  to 
complain  of  amenorrhoea.  Night  sweats  are  an  important 
early  symptom  :  the  patient  wakes  at  night  drenched  with 
a  cold  perspiration.  In  other  cases  pain  in  the  chest, 
the  result  of  a  dry  pleurisy,  may  be  the  earliest  sign.  More 
commonly  the  jDatient  will  seek  advice  because  of  a  persistent 
cough  often  dating  from  a  cold  in  the  chest  some  few  weeks 
or  months  previously.  Along  with  the  cough  there  will 
be  expectoration,  unless  it  is  the  dry  hacking  cough  of 
pleurisy,  and  possibly  some  haemoptysis. 

Hcemoptysis  may  be  the  first  symptom  to  make  the  patient 
think  he  is  ill ;  early  haemoptysis  is  usually  slight,  the  sputum 
is  streaked  with  bright-red  blood,  or  there  may  be  small 
quantities  of  nearly  pure  blood,  frothy  from  admixture  with 
air  or  in  the  form  of  clots.  This  haemorrhage  is  produced 
by  diapedesis  from  the  congestion  of  the  capillaries,  which 
is  the  result  of  the  early  inflammatory  reaction  ;  it  is  com- 
parable to  the  haemorrhage  in  the  early  days  of  pneumonia. 

Late  haemoptysis  often  results  from  the  rupture  of  a  blood- 
vessel in  the  wall  of  a  vomica.     Those  vessels  which  cross  a 


SPECIFIC   INFECTIVE   DISEASES 


93 


cavity  from  one  side  to  the  other  are  nearly  always  throm- 
bosed, and  so  do  not  cause  haemorrhage  ;  but  those  which  run 
in  the  wall  of  a  cavity  are  likely  to  form  locahsed  aneurysms 
at  their  most  unsupported  parts.  These  aneurysms  project 
into  the  cavity  and  are 
prone  to  rupture  with  the 
production  of  more  or  less 
profuse  haemoptysis. 

The  sputum  in  the  early 
stages  is  muco  -  purulent  : 
as  the  disease  progresses  it 
becomes  more  and  more 
purulent,  eventually 
assuming  the  form  of 
isolated  greenish-grey  flat- 
tened discs  which  sink  in 
water.  In  our  opinion  too 
much  importance  has  been 
attributed  to  this  nummular 
form  of  sputum  in  the 
diagnosis  of  tuberculosis  ; 
the  real  importance  of  the 
sputum  lies  in  the  fact  that 
it  can  be  examined  for 
tubercle  bacilli  and  elastic 
tissue.  To  examine  for 
tubercle  bacilli,  vide  p.  81. 

To  examine  for  elastic 
tissue  one  of  the  purulent 
particles  should  be  squeezed 

out  between  two  cover-slips.  If  examined  with  a  hand 
lens  against  a  black  background,  elastic  tissue  can  often 
bo  recognised  as  small  yellow  shreds  arranged  in  a  network. 
If  it  cannot  be  recognised  in  this  manner,  some  sputum 
should  be  boiled  with  an  equal  quantity  of  caustic  soda 
solution  (20  gr.  to  1  oz.)  until  the  mixtiii(!  is  hquid.  The 
fluid  shoukl  tlien  be  centrifugalised  and  the  deposit 
examined  microscopically.  For  certain  diagnosis  the 
alveolar  airangoinent  of  the  elastic  tissue  fibres  sliould  be 
made  out. 


i 
1 

1 

1 

101' 
lOS' 

I04f 
103° 

lot 

101' 
100" 
99' 

96' 

i.9S' 

1*0 

130 

no 
no 

100 

90 
to 

70 
60 

rso 
ss 

45 

31 
25 

M    E 

M   E 

M  E 

M  E 

M   E 

M  E 

ME 

M  E 

M   E 

■A 

■  S 

■A 

•A 

i\ 

■:A 

l\ 

:A 

1 

\ 

\ 

i 

/ 

l\ 

4- 

\h 

A. 

\h 

Y_. 

\h 

/■ 

:/• 

». 

I 

W 

][] 

J 

¥ 

V 

V. 

\ 

■ 

/ 

•A 

'■l^ 

(A 

n 

i^ 

J' 

J 

/ 

\A 

A 

I 

-. 

v; 

V 

v/ 

v/ 

V: 

V 

\: 

: 

A 

;A 

.i^ 

,  ;A 

i  A 

r 

^ 

v^ 

\ 

V 

V 

V 

V 

V 

Fig.  2").-  Chart  from  a  case  of  rapidly 
progressing  Fibro-caseous  Tuber- 
culosis of  the  Lunjrs. 


94 


MEDICAL  DIAGNOSIS 


Dyspnoea  is  not  a  striking  feature  of  early  cases,  but  as 
the  disease  advances  there  is  often  considerable  breathless- 
ness  after  exertion.  In  verj^  chronic  cases,  where  there  is 
considerable  fibrosis  of  one  or  both  lungs,  true  cardiac 
dyspnoea  occurs  from  embarrassment  of  the  right  heart. 

Fever  is  present  in  the  great  majority  of  aU  cases  ; 
the  pyrexia  is  regular,  showing  an  evening  rise  and  falling 
to  below  normal  during  the  early  hours  of  each  morning. 
A  small  percentage  of  cases  show  the  inverse  type  of  tempera- 
ture with  a  morning  rise  and  an  evening  fall,  which  is  pro- 
bably due  to  the  formation  of  fresh  miliary  tubercles.     The 


1 

106' 

ics' 

10*° 
103° 

m° 

101° 

M    E 

M  e 

M   E 

M   E 

M    E 

M  E 

M  e 

M  E 

ME 

M   E 

MEM 

E 

; 

• 

99° 
98' 
97° 
Oft" 

-"W 

■"'^ 

._. 

''T- 

... 

■i"« 

... 

... 

"^ 

•tA 

.-.  .. 

,. 

/:■ 

^ 

V^ 

^ 

V 

^••^ 

V^^ 

V 

V 

\/^ 

/' 

_ 

Fig.  26. — Chart  of  the  Temperature  in  a  case  of 
(quiescent  Fibro-caseous  Pulmonary  Tuber-J 
culosis. 

swinging  type  of  temperature  is  of  great  importance  in 
the  diagnosis  of  tuberculosis  ;  it  is  very  constant,  and  even 
in  those  cases  in  which  the  maximum  temperature  is  never 
more  than  99°  the  temperature  will  generally  show  a  daily 
variation  of  more  than  one  degree,  and  so  conform  to  type. 

It  is  important  that  the  temperature  should  be  taken  every 
four  hours,  or  even  more  often,  as  if  the  temperature  be 
taken  only  in  the  morning  or  evening  the  characteristic 
variation  may  not  be  so  apparent.  A  persistent  rise  of 
temperature  after  exertion  is  of  especial  value  both  in  diag- 
nosis and  in  gauging  the  effect  of  treatment. 

The  pulse  is  usually  accelerated  in  proportion  to  the 
temperature — it  is  often  fuU  and  soft ;  except  in  advancing 
disease,  it  is  usually  below  ninety.  A  persistent  rise  in 
frequency  after  exercise,  even  though  unaccompanied  by 
fever,  is  a  sign  that  the  patient  has  done  too  much. 


SPECIFIC   INFECTIVE   DISEASES  95 

The  blood  pressure  is  nearly  always  subnormal. 

(3)  Physical.  Signs.  Inspection  of  the  chest  may 
reveal  a  long  fiat  narrow  thorax  with  wide  intercostal  space 
and  narrow  costal  angle.  The  supra-  and  infra-clavicular 
fossae  are  often  well  marked,  while  the  scapulse  may  be  promi- 
nent or  winged.  Asymmetry  of  the  upper  chest,  particularh- 
in  the  direction  of  flattening  or  retraction  at  one  apex, 
is  important ;  impaired  mobility  of  one  side,  again  particu- 
larly the  upper  part,  is  often  of  early  occurrence. 
Lastly,  displacement  of  the  cardiac  impulse  may  result 
from  the  heart  being  pulled  in  the  direction  of  a  fibrosed 
area. 

Palpation  A\ith  the  Hat  of  the  hand  will  show  impaued 
mobihty,  and  comparison  of  the  vocal  fremitus  in  diflt'erent 
regions  will  show  an  increase  in  the  vicinity  of  the  affected 
parts.  It  must  be  remembered  that  vocal  fremitus  is^  nor- 
mally better  appreciated  at  the  right  apex  than  the  left,  but 
any  marked  difference  is  of  signiticance. 

Percussion  may  give  a  relatively  dull  note  either  from 
diminished  air  entr}',  consolidation,  thickened  plem'a,  or  a 
cavity  filled  with  secretion.  Valuable  information  may  be 
gained  by  direct  percussion  on  the  clavicles.  A  tympanitic 
note  may  be  obtamed  where  there  is  central  cavitation 
covered  by  crepitant  lung,  or  over  an  empty  cavity  if  near 
the  surface.  A  cavity  communicating  with  an  open 
bronchus  may  give  a  "  crack-pot  "'  sound  if  the  patient  has 
his  mouth  open  at  the  moment  of  percussion,  but  it  should 
be  remembered  that  this  sound  may  often  be  obtained  in 
healthy  children  if  they  are  crying.  In  early  cases  the  per- 
cussion signs  may  be  most  indefinite,  and  it  is  then  that  sig- 
nittcance  must  be  attached  to  any  relative  difference  on  the 
two  sides  of  the  chest.  It  is  important  to  remember  that 
normaUy  the  percussion  note  is  rather  higher  pitched  at 
the  right  apex  than  at  the  left. 

Auscultation.  Diminished  air-entry,  and  especiahy  a 
prolongation  of  expiration  \\  ith  a  feeble  or  nearly  inaudible 
inspiration,  are  amongst  the  earliest  signs.  As  the  disease 
becomes  more  advanced  adventitious  sounds  may  appear. 
A  localised  line-tube  bronchitis  is  significant.  When 
softening  has    occurred   there   are   hkely   to   be  line,   liaid 


96  MEDICAL   DIAGNOSIS 

crepitations,  often  possessed  of  a  metallic  character  ;  these 
are  best  heard  during  and  at  the  end  of  inspiration.  They 
may  often  be  heard  as  a  shower  of  harsh  clicks  accompanying 
inspiration  if  the  patient  has  just  previously  been  made  to 
cough.  Persistence  or  increase  after  coughing  of  harsh 
crackles  over  a  localised  area  of  lung  is  perhaps  the  most 
important  diagnostic  point,  and  such  crackles  are  termed 
post-tussive.  Consolidation,  if  at  all  extensive,  will  cause 
broncho-vesicular  or  tubular  breathing,  while  amphoric 
phenomena  will  be  obtained  over  an  empty  cavity  of  suffi- 
cient size. 

Vocal  resonance  is  likely  to  be  increased  throughout  the 
diseased  area,  while  bronchophony  and  pectoriloquy  are 
usual  over  both  solid  lung  and  cavities. 

Pleurisy  is  the  rule  at  some  stage  or  other,  so  that  a 
respiratory  rub  may  be  audible  at  any  period  of  the  disease  ; 
it  is  often  one  of  the  earliest  phenomena. 

In  many  cases  the  physical  signs  as  above  described  will 
be  so  obvious  as  to  make  the  diagnosis  a  matter  of  no  diffi- 
culty ;  in  other  cases,  however,  a  very  careful  examination 
will  be  needed  before  the  affected  area  can  be  discovered. 
In  such  cases  it  is  of  special  importance  to  remember  the 
most  likely  situations  for  the  presence  of  early  lesions  and 
carefully  to  contrast  suspected  spots  with  the  corresponding 
areas  of  the  other  lung.  The  apical  lesions  are  most  readily 
detected  in  the  supra-spinous  fossse  behind,  and  just  below  the 
middle  of  the  clavicle  in  front.  Below  the  outer  third  of  the 
clavicle  in  front  is  another  likely  situation.  Lesions  starting 
in  the  upper  part  of  the  lower  lobes  can  best  be  detected  by 
examining  at  the  level  of  the  fourth  and  fifth  dorsal  spines 
behind  and  about  two  inches  from  the  middle  line.  The 
interlobar  septum  must  also  be  examined  ;  the  line  for  this 
can  be  judged  by  placing  the  patient's  hand  on  his  other 
shoulder  and  examining  along  the  lower  border  of  the 
scapula. 

It  remains  to  be  said  that  sometimes  the  most  pains- 
taking examination  may  reveal  no  trace  of  the  disease  ;  for 
such  cases  certain  special  methods  of  diagnosis  must  be 
employed  {vide  pp.  105 — 110). 

{d)  Fibroid   Tuberculosis.     A  fibroid  lung  is  not   neces- 


SPECIFIC   INFECTIVE   DISEASES 


97 


sarily  tuberculous,  but  chronic  cases  of  fibro-caseous  disease 
often  become  fibroid.  Fibrosis  may  also  follow  tuberculous 
pleurisy  and  the  pneumonic  forms  of  pulmonary  tuber- 
culosis should  the  patient  survive.  On  the  other  hand, 
tuberculosis  may  occur  as  a  secondary  infection  in  a  lung 
fibrosed  from  other  causes,  such  as  non-tuberculous  pleurisy, 
with  or  without  effusion,  unresolved  lobar  pneumonia, 
chronic  bro^icho -pneumonia,  and  the  late  stages  of  the 
various  forms  of  pneumono-koniosis. 

The  diagnosis  of  a  fibroid  lung  is  easy,  but  it  is  only 
possible  to  say  whether  it  is  fibroid  tuberculosis  by  demon- 
strating tubercle  bacilli  in  the  sputum.  They  are  generally 
present  if  there  is  active  tuberculosis,  but  sometimes  the 
tuberculous  factor  may  become  obliterated  as  the  fibrosis 


i 
1 

IDS' 
lOS' 

la*' 

,03' 
102' 
101' 
100" 
SS' 
98' 

ar« 
90" 

M    E 

M    E 

M   E 

M  E 

M    E 

ME 

M  E 

M  E 

M   E 

M   E 

M   E 

M  E 

: 

: 

"?A 

[■^ 

... 

•Yt 

•1^ 

■7^ 

.jO 

''K 

"f^ 

"/ 

¥ 

r; 

/ 

V- 

'^  s 

f 

^. 

/ 

\/^ 

n/ 

\/ 

7 

V 

Fig.  27. — Chart  to  show  the  sub-normal  tempera- 
ture seen  in  many  cases  of  Fibroid  Tuberculosis. 

advances.  At  the  same  time  it  must  be  remembered  that 
tuberculosis  is  the  commonest  cause  of  fibroid  lung. 

The  symptoms  of  fibroid  tuberculosis  are  cough,  which  is 
often  paroxysmal,  and  increasing  dyspnoea  on  exertion. 
The  sputum  is  purulent  and  varies  in  amount  according  to 
the  degree  of  co-existent  bronchiectasis.  Ha3moptysis  is 
common.  There  is  very  gradual  loss  of  weight  and 
strength  ;    pyrexia  is  usually  absent. 

The  physical  signs  are  shrinking  and  retraction  of  the 
affected  side  with  marked  impairment  of  mobility  ;  there  is 
dulness  to  percussion,  but  tactile  fremitus  and  vocal  reso- 
nance are  usually  increased.  The  heart  is  disphiced  towards 
the  lesion,  and  bronchial  or  tubular  breathing  is  often  heard, 
especially  at  the  apex.    (See  also  "  Lungs,  Fibrosis  of,"  p.  2U4.) 

M.D.  7 


98  MEDICAL   DIAGNOSIS 


IV.   TUBERCULOSIS    OF   THE    ALIMENTARY 
TRACT. 

It  is  probable  that  the  frequency  with  which  the  cervical 
lymph  glands  become  affected  with  tuberculosis  is  due  to 
the  passage  of  tubercle  bacilli  through  the  tonsils.  The 
bacilli  can  be  demonstrated  in  a  fair  proportion  of  all  tonsils 
removed  for  chronic  hypertrophy,  even  though  they  have 
not  formed  a  local  lesion.  Sometimes,  however,  it  happens 
that  a  local  deposit  is  formed,  in  which  case  caseation  and 
ulceration  result. 

The  tongue,  pharynx,  and  palate  may  occasionally  be 
affected  in  the  late  stages  of  pulmonary  tuberculosis.  A 
ragged  spreading  ulcer  with  a  rough  and  sometimes  caseous 
base  is  formed.  The  presence  of  signs  of  tuberculosis  else- 
where will  suggest  the  diagnosis.  If  there  is  any  doubt  a 
small  piece  of  the  ulcer  may  be  excised  and  examined 
histologically,  films  may  be  made  from  scrapings  and  stained 
for  the  bacilli,  or  guinea-pigs  may  be  inoculated  with  an 
emulsion  in  saline  of  material  scraped  from  the  floor  of  the 
ulcer. 

The  intestine  may  be  infected  secondarily  from  the  sputum 
of  patients  with  pulmonary  tuberculosis  ;  it  may  also  be 
infected  primarily  in  children.  The  parts  commonly  affected 
are  the  Peyer's  patches  in  the  lower  three  feet  of  the  ileum 
and  the  solitary  follicles  in  the  caecum  and  in  the  first  part 
of  the  colon. 

The  symptoms  of  intestinal  tuberculosis  are  very  vari- 
able ;  diarrhoea  is  common,  sometimes  there  is  melaena, 
and  profuse  haemorrhages  are  occasionally  seen. 

If  the  disease  is  localised  to  the  caecum  the  symptoms  may 
simulate  appendicitis.  In  an  adult  the  presence  of  pulmonary 
tuberculosis  might  suggest  the  correct  diagnosis.  Where 
there  are  no  signs  of  tuberculosis  elsewhere  a  blood  examina- 
tion may  prove  of  value,  a  lymphocytosis,  relative  or 
absolute,  being  a  common  accompaniment  of  tuberculous 
lesions.  The  special  methods  for  the  diagnosis  of  tuber- 
culosis (p.  105)  should  also  be  employed.  Perforation  or 
peritonitis,  either  local  or  diffuse,  are  possible  sequelae. 


SPECIFIC   INFECTIVE   DISEASES  99 

Fistula  in  ano  and  chronic  ischio-rectal  abscess  are 
frequently  tuberculous  in  origin. 

V.   TUBERCULOSIS   OF   SEROUS   MEMBR.\NES. 

Pleurisy  due  to  tuberculous  infection  may  be  primary  or 
secondary  ;  miliary  tubercles  are  often  found  on  the  pleura 
without  any  signs  of  pleurisy  in  cases  of  generalised  tuber- 
culosis. In  secondary  cases  there  maybe  the  physical  signs 
of  the  underlying  pulmonary  condition. 

The  symptoms  and  physical  signs  of  a  tubercidous  pleurisy 
do  not  differ  from  those  of  pleurisy  produced  from  other 
causes  {vide  p.  304).  Tuberculous  pleurisy  may  be  dry  or 
sero-fibrinous ;  in  secondary  cases  it  may  occasionally  be 
purulent. 

TJte  diagnosis  of  tuberculous  from  other  pleurisies  \\\\^  depend 
upon  the  evidence  ot  tuberculosis  elsewhere,  the  special 
methods  for  diagnosing  tuberculosis  (p.  105),  and,  if  there 
is  effusion,  on  the  examination  of  the  fluid  withdrawn  \>y  an 
exploring  syringe  or  by  aspiration.  The  fluid  so  obtained 
should  be  placed  in  a  sterile  bottle  ;  it  is  usually  clear  or 
slightly  turbid  and  of  a  pronounced  yellow  colour  ;  it  is 
highly  albuminous.  The  fluid  should  be  centrifugalised  and 
cultures  made  from  the  deposit  on  various  nutrient  media  ; 
films  should  also  be  spread  for  immediate  examination,  and 
it  may  be  desirable  to  inoculate  some  of  the  deposit  into  the 
peritoneum  of  a  guinea-pig. 

The  fihn  preparations  will  show  a  considerable  number  of 
lymphocytes,  a  variable  number  of  endothelial  cells  from 
the  pleura,  and  a  complete  absence  of  all  organisms.  In 
very  rare  cases  tubercle  bacilli  may  be  found.  The  culture- 
tubes  will  yield  no  growth,  but  the  guinea-pig  will  generally 
be  found  to  be  tuberculous  if  killed  after  an  interval  of  six 
weeks.  It  is  important  to  remember  that  apparently 
])rimary  pleurisies  with  the  characters  above  described, 
even  though  the  inoculation  test  be  negative,  must  be 
regarded  as  tuberculous.  The  truth  of  this  is  emphasised 
by  the  frequency  with  which  patients  presenting  themselves 
with  signs  of  early  pulmonary  tuberculosis  will  give  a  history 
of  pleurisy  some  few  years  previously. 

7—2 


100  MEDICAL   DIAGNOSIS 

The  peritoneum  is  commonly  affected,  primarily  in  children 
via  the  intestinal  canal,  and  secondarily  in  adults  through 
the  swallowing  of  tuberculous  sputum  or  possibly  by  the 
spread  of  infection  through  the  Fallopian  tubes  or  epidi- 
dymes  and  seminal  vesicles.  In  primary  cases  the  mesen- 
teric glands  are  always  involved  as  well.  Two  varieties 
are  described,  one  in  which  ascites  is  a  prominent  feature 
and  the  other  in  which  there  is  a*  prominent  doughy 
abdomen,  often  with  palpable  masses  of  omentum  or  glands, 
and  little  if  any  effusion. 

The  symptoms  are  extremely  variable — indeed,  they  may 
be  entirely  wanting ;  in  like  manner  great  variations  in  the 
acuteness  of  the  disease  may  be  encountered.  In  the  more 
severe  cases  there  will  be  general  ill-health  with  gradual 
wasting,  abdominal  pain  and  tenderness,  diarrhoea,  and  a 
swinging  temperature.  Examination  will  reveal  a  prominent 
and  distended  abdomen,  sometimes  with  effusion,  but  more 
commonly  of  a  doughy  or  lumpy  consistency.  The  disease 
is  often  very  chronic,  and  in  such  cases  a  persistently  sub- 
normal temperature  may  be  found.  At  the  same  time  the 
temperature  is  likely  to  show  a  definite  daily  variation. 
In  children  the  diagnosis  does  not  as  a  rule  present  much 
difficulty  :  enteric  fever  can  be  distinguished  by  the  Widal 
reaction  ;  cirrhosis  of  the  liver  is  rare  in  children,  as  also 
are  cancerous  and  other  tumours  in  the  abdomen.  Coeliac 
disease  must  always  be  excluded  {vide  p.  366). 

In  adults  the  presence  of  other  tuberculous  lesions  is  of 
extreme  importance.  The  history  and  general  appearance 
may  suggest  cirrhosis.  In  cases  where  there  is  a  palpable 
tumour  there  may  be  evidence  of  a  primary  growth  in  the 
stomach  or  pelvis.  Where  there  is  a  sacculated  effusion 
in  tuberculous  peritonitis  the  diagnosis  from  ovarian  cyst 
may  be  impossible  ;  the  irregular  temperature,  progressive 
emaciation,  and  gas tro -intestinal  disturbance  would  be  in 
favour  of  tuberculosis,  while  a  careful  bimanual  examina- 
tion might  help  to  establish  the  diagnosis  of  ovarian  cyst. 

Acute  septic  peritonitis  is  usually  accompanied  by  con- 
stipation, vomiting,  and  a  pulse  more  rapid  and  thread-like 
than  that  of  tuberculous  peritonitis  ;  further,  the  abdomen 
is  hkely  to  be  rigid,  fixed  and  not  moving  with  respiration. 


SPECIFIC   INFECTIVE   DISEASES  101 

At  the  same  time  tuberculous  peritonitis  may  be  very  acute  ; 
it  is  almost  the  only  condition  which  ever  produces  a  red, 
fluctuating  swelling  pointing  at  the  umbilicus  though 
obviously  of  intra-abdominal  origin.  In  doubtful  cases 
valuable  information  may  be  gained  from  the  special  tests 
discussed  on  p.  105. 

VI.    TUBERCULOSIS    OF   THE   LYMPHATIC 
GLANDS. 

The  younger  the  patient  the  more  liability  is  there  to 
tuberculous  adenitis.  The  most  common  glands  to  be 
affected  are  those  in  the  anterior  cervical  triangles,  the 
mesenteric  and  the  bronchial  glands,  but  the  axillary  and 
inguinal  may  also  be  involved.  The  process  is  often  very 
indolent,  the  glands  remaining  permanently  enlarged/ to  a 
greater  or  less  extent  and  very  subject  to  periodical  exacer- 
bations. There  is  a  tendency  for  neighbouring  glands  to 
become  fused  together  into  a  nodular  mass  ;  whilst  sooner 
or  later  softening  is  apt  to  occur  and  give  rise  to  fluctuation. 
Eventually  there  is  ulceration,  and  in  the  case  of  subcu- 
taneous glands  tuberculous  sinuses  are  formed,  while  the 
bronchial  glands  may  ulcerate  into  a  bronchus  or  a 
blood-vessel,  producing  tuberculous  broncho-pneumonia 
or  generalised  tuberculosis  respectively.  The  mesenteric 
glands  do  not  commonly  break  down  ;  they  may  be 
met  with  as  the  sole  infection  or  in  conjunction  with 
tuberculous  peritonitis.  In  the  former  case  there  may 
be  no  symptoms  or  there  may  be  evidence  of  obscuro 
toxaemia  ;  sometimes  there  are  definite  abdominal  symp- 
toms, such  as  diarrhoea  and  distension,  and  in  such  cases 
the  condition  may  be  confounded  with  enteric  fever 
{vide  p.  2.3).  The  glands  are  rarely  palpable,  but  some- 
times they  may  form  a  definite  tumour.  Tuberculosis 
of  the  bronchial  glands  may  never  be  suspected  ;  it  may, 
however,  give  rise  to  general  symptoms  of  pyrexia,  debility, 
and  wasting,  and  if  the  glands  become  very  large  they  may 
obstruct  the  bronchi  or  implicate  the  recurrent  laryngeal 
nerve,  giving  rise  to  spasmodic  cough,  stridor,  bronchitis, 
collapse  of  lung,  and  laryngeal  palsy.     Sometimes  they  may 


102  MEDICAL   DIAGNOSIS 

be  detected  by  means  of  an  unwonted  dulness  to  percussion 
over  the  upper  part  of  the  sternum  and  in  the  absence  of 
physical  signs  they  may  sometimes  be  recognised  as  dark 
shadows  in  X-ray  photographs  of  the  thorax. 

Tuberculosis  of  the  cutaneous  lymph  glands  must  not 
be  mistaken  for  the  following  conditions  : — 

(1)  Septic  Adenitis.  The  presence  of  a  septic  focus, 
such  as  tonsillitis,  pediculosis  capitis,  or  sores  about  the 
hands  or  feet,  etc.,  should  prevent  this  mistake  so  far  as 
the  corresponding  glands  are  concerned. 

(2)  Lympliadenoma  {vide  p.  169). 

(3)  Lymphatic  Leukcemia.  A  systematic  examination  of 
the  blood  will  establish  the  diagnosis  of  this  condition  {vide 
p.  165). 

(4)  Lymphosarcoma.  The  blood  picture  here  may  possibly 
approximate  to  that  of  leukaemia  ;  softening  is  extremely 
rare,  and  there  is  often  evidence  that  the  mediastinal  glands 
are  involved.  If  there  is  any  doubt  a  gland  should  be  excised 
and  submitted  to  microscopical  examination. 

(5)  Secondary  Carcinomatous  Adenitis.  Careful  examina- 
tion should  reveal  a  primary  growth. 

It  is  to  be  noted  that  glandular  tuberculosis  is  the  most 
favourable  form  of  tuberculous  infection.  Many  cases 
undergo  spontaneous  cure  even  after  a  long  period. 

VII.   TUBERCULOSIS   OF   THE   URINARY 
SYSTEM. 

(a)  Renal  Tuberculosis.  The  kidney  may  theoretically 
be  infected  in  one  of  several  manners  : — 

(1)  By  the  blood-stream,  in  which  case  the  bacilli  are 
deposited  either  in  the  walls  of  the  blood-vessels,  or  they 
may  escape  from  the  blood-vessels  through  the  glomerular 
tuft  into  the  convoluted  tubules,  whence  they  may  be 
excreted  or  they  may  lodge  in  the  pyramids. 

(2)  By  an  ascending  infection  from  the  bladder  along  the 
ureter  to  the  pelvis.  It  is  probable  that  this  method  is 
rare. 

(3)  By  extension  from  the  lower  urinary  tract  along  the 
lymphatics. 


SPECIFIC   INFECTIVE   DISEASES  103 

It  is  now  generally  accepted  that  the  first,  or  hsemato- 
genous,  route  is  by  far  the  most  common.  We  are  not  now 
concerned  with  the  deposit  of  miliary  tubercles  in  the  course 
of  a  generalised  tuberculosis,  but  rather  with  those  cases  in 
which  the  lesion  in  the  kidney,  at  first  at  any  rate,  is  localised. 

Diagnosis.  The  condition  is  likely  to  be  met  with  in 
3'oung  adults.  The  earliest  sijmptoms  will  be  polyuria  with 
frequency  of  micturition,  which  at  first  is  painless,  shght 
albuminuria  with  the  presence  of  a  few  pus  cells  but  no  casts 
in  acid  urine  and  occasional  hsematuria  with  the  passage  of 
small  clots  of  blood.  It  is  significant  that  the  above 
symptoms  are  often  remittent  for  a  considerable  time. 

In  more  advanced  cases  there  ma}-  be  pain  in  the  loin  with 
an  enlarged  tender  and  palpable  kidney  and  a  certain  amount 
of  dysuria,  at  the  same  time  as  pyrexia,  wasting  and  general 
ill-health.  As  a  first  step  towards  establishing  the  diag^iosis 
the  urine  must  be  tested  for  the  presence  of  tubercle  bacilli 
{ride  p.  81 ).  If  no  bacilli  are  found,  it  is  advisable  to  inoculate 
a  guinea-pig  with  some  of  the  centrifugalised  urinary  deposit. 
At  the  same  time  assistance  maj^  be  gained  from  von  Pirquet's 
test  and  the  estimation  of  the  opsonic  index  (riV/epp.  107 — 
108).  The  cystoscope  should  now  be  employed.  In  skilful 
hands  a  positive  diagnosis  can  be  made  with  certainty  at 
a  very  early  stage  by  the  use  of  this  instrument. 

The  cystoscope  will  show  the  presence  of  tuberculosis  of 
the  bladder  or  of  the  ureteric  orifices  ;  and,  further,  it  is 
possible  to  estimate  the  health  of  the  corresponding  kidney 
by  the  appearance  of  each  ureteric  opening  and  the  size, 
regularity,  and  frequency  of  the  jets  of  urine  which  escape 
from  it.  The  quality  of  the  urine  produced  by  each  kidney 
can  be  observed,  and  if  necessary  the  urines  can  be  collected 
separately  by  means  of  ureteric  catheterisation.  An 
abnormal  ureteric  orifice,  particularly  in  the  direction  of 
congestion,  enlargement  or  erosion,  practically  alwaj-s 
means  an  abnormal  kidney  on  the  afi^ected  side.  A  normal 
ureter  shoots  into  the  bladder  a  jet  of  from  10  to  15  drops 
every  thirty  to  forty  seconds.  If  the  kidney  is  irritated, 
the  urine  escapes  more  frequently  and  in  less  amount  ;  if, 
however,  the  kidney  is  compensating  by  over-activity  for 
its   diseased   fellow,   the   jets   are  frequent,   prolonged   and 


104  MEDICAL   DIAGNOSIS 

copious.  Proof  positive  may  often  be  furnished  by  the 
sight  of  pus  or  blood  escaping  from  one  ureter. 

(6)  Tuberculosis  of  the  Bladder.  This  is  practically  never 
primary,  it  may  be  secondary  on  the  one  hand  to  renal 
tuberculosis,  or  on  the  other  hand  to  tuberculosis  of  the 
seminal  vesicles,  which  in  turn  become  infected  from  the 
epididymis.  The  symptoms  are  those  of  chronic  cystitis 
with  pus,  albumin,  and  epithelial  cells  in  acid  urine  ;  there  is 
often  but  little  pain.  The  discovery  of  tubercle  bacilli  and 
the  use  of  the  cystoscope  make  diagnosis  easy.  An  examina- 
tion with  X-rays  should  prevent  either  renal  or  vesical 
tubercle  being  mistaken  for  calculus  in  these  organs. 

It  is  noteworthy  that  tuberculosis  and  the  presence  of 
pyelitis  or  cystitis  due  to  the  Bacillus  coli  communis  are  the 
most  common  causes  of  pus  in  acid  urine. 

VIII.   TUBERCULOSIS    OF   THE   SKIN. 

Tuberculous  skin  lesions  may  arise  in  three  ways — by 
direct  infection  through  the  skin  ;  by  the  spread  of  infection 
from  breaking  down  of  infected  lymphatic  glands  ;  and  by 
the  circulation  of  tuberculous  toxins  generated  in  some 
visceral  lesion. 

Lupus  Vulgaris  is  the  most  common  cutaneous  tuber- 
culide. This  condition  is  most  frequently  met  with  on  the 
face,  often  starting  in  the  mucous  membrane  or  skin  of  the 
nose.  The  earliest  manifestation  is  a  small  raised  yellowish- 
brown  translucent  nodule  ;  several  of  these  nodules  run 
together,  forming  a  patch  in  the  centre  of  which  ulceration 
occurs.  The  ulcer  spreads  slowly,  healing  in  one  part 
while  extending  at  another  and  eroding  as  it  goes  all  tissues 
except  bone.  The  disease  nearly  always  starts  in  childhood 
or  adolescence  and  runs  an  extremely  chronic  course. 
Serious  deformities  may  be  produced  by  the  cicatricial  con- 
traction. The  appearance  of  the  spreading  ulcer  with 
ragged  edges,  on  which  the  "  apple-jelly  "  nodules  are 
visible,  is  sufficiently  characteristic. 

Syphilis  maybe  distinguished  by  the  Wassermann  reaction 
and  Lupus  erythematosus  by  its  late  onset,  its  symmetrical 
appearance,  and  the  absence  of  ulceration. 


SPECIFIC   INFECTIVE   DISEASES  105 

If  there  is  any  doubt  a  small  piece  of  the  edge  of  the  ulcer 
may  be  excised  and  the  histological  characteristics  of  tuber- 
culosis demonstrated  microscopically.  This  last  manoeuvre 
(biopsy)  will  also  serve  to  distinguish  readily  lupus  vulgaris 
from  rodent  ulcer. 

Cutaneous  Tuberculides  due  to  direct  inoculation  are  usually 
seen  as  greyish-white,  warty  outgrowths  ;  ulceration  is 
rare,  but  pustules  not  infrequently  form  as  the  result  of 
secondary  pyogenic  infection.  The  processes  may  be  single 
or  grouped  together,  and  sometimes  spread  peripherally 
while  heahng  at  the  centre.  Microscopical  examination  after 
excision  will  show  the  characteristic  giant-cell  systems  of 
tuberculous  infiltration. 

The  Toxic  Cutaneous  Tuberculide  is  an  important  mani- 
festation, since  it  may  sometimes  be  the  first  evidence 
that  there  is  active  tuberculosis  elsewhere.  The  lesions^  are 
commonly  met  with  on  the  legs  or  forearms  ;  they  occur 
at  first  as  painless  but  sometimes  irritable  localised  red 
swellings.  They  are  apt  to  spread  until  considerable  areas 
are  involved,  thus  causing  a  slightly-raised,  soft,  shiny  red 
patch.  In  the  centre  of  this  patch  necrosis  may  occur, 
causing  a  punched-out  ulcer  with  a  yellowish-grey  base  ; 
this  ulcer  may  spread  till  it  becomes  of  considerable  size. 
No  tubercle  bacilli  arc  present  in  this  last  variety,  though 
they  can  generally  be  found  in  lupus  and  in  the  tubercu- 
lous warts. 

IX.    SPECIAL  METHODS   OF  USE   IN   THE 
DIAGNOSIS   OF   TUBERCULOSIS. 

(1)  X-ray  Diagnosis.  This  method  may  be  of  service  in 
cases  of  pnliiionary  tuberculosis  and  tuberculous  enlarge- 
ment of  the  thoracic  glands,  but  in  no  case  does  it  tell  us 
whether  the  disease  is  active  or  quiescent.  In  all  cases  screen 
examinations  should  first  be  made  and  subsequently  short- 
exposure  phot()gra])hs  taken  of  the  thorax  in  different  planes. 
Tuberculous  infiltration  of  the  lungs  can  often  be  detected  as 
mottled  areas  of  })artial  opacity  either  localised  or  diffuse, 
according  to  the  distribution  of  the  lesions.  Even  in  very 
early  lesions  there  is  likely  to  be  restricted  movement  of  the 


106  MEDICAL   DIAGNOSIS 

affected  lung,  and  the  consequent  diminution  in  the  excur- 
sion of  the  diaphragm  on  that  side  is  well  shown  by  the 
fluoroscopic  screen.  Enlarged  glands  may  be  seen  as  dark 
shadows  about  the  root  of  the  lung  and  along  the  course  of 
the  main  bronchi.  An  enlarged  kidney  may  occasionally  be 
recognised  in  a  photograph  before  it  can  be  detected  by 
palpation. 

(2)  Diagnosis  by  the  Hypodermic  Injection  of  Koch's  Old 
Tuberculin.  It  is  preferable  to  use  tuberculin  A.F.,  as  this 
has  the  same  value  as  old  tuberculin,  but,  being  free  from 
albumoses,  is  less  likely  to  lead  to  anaphylactic  phenomena 
which  may  give  rise  to  ambiguous  results.  A  reaction,  if 
it  occurs,  usually  follows  an  injection  in  twelve  hours,  but 
may  be  delayed  to  thirty-six  hours.  It  may  be  either 
{a)  local,  i.e.,  redness  and  infiltration  at  the  site  of  injection  ; 

(b)  general,    i.e.,   malaise,   headache,    pains   in   the   limbs ; 

(c)  febrile  to  the  extent  of  1°  F.  or  more,  or  (d)  focal,  i.e., 
causing  changes,  chiefly  due  to  hypersemiain  the  lesion  itself , 
which  in  the  case  of  pulmonary  disease  is  shown  by  an  increase 
of  adventitious  sounds  and  an  increase  in  expectoration. 
Any  or  all  of  these  reactions  may  occur  in  a  given  patient. 
As  a  rule  a  reaction  seldom  lasts  more  than  twenty-four 
hours.  A  positive  reaction  shows  the  presence  of  a  tuber- 
culous lesion,  but  gives  no  evidence  as  to  whether  the  lesion 
is  active  or  quiescent.  At  the  same  time  a  reaction,  and 
especially  a  focal  reaction,  may  do  much  in  a  given  case  to 
strengthen  suspicion  of  the  presence  of  tuberculosis. 

The  patient  should  be  kept  in  bed  for  forty-eight  hours 
before  an  injection  for  the  purpose  of  obtaining  a  four- 
hourly  record  of  the  temperature.  The  first  injection 
should  be  "001  cc.  tuberculin  A.F.  ;  if  no  reaction  occur, 
•05  cc.  may  be  injected  at  the  end  of  forty-eight  hours, 
and  if  no  reaction  follow  now,  "01  cc.  may  be  injected  at 
the  end  of  a  further  forty-eight  hours.  If  this  causes  no 
reaction,  tuberculosis  can  be  excluded.  In  young  children 
or  weakly  people  the  first  dose  should  be  smaller  ;  if  there 
is  some  disturbance  after  an  injection,  but  not  sufficient 
to  be  called  a  reaction,  the  increase  in  dosage  should  be 
smaller. 

The  test  should  be  confined  to  cases  in  which  the  evidence 


SPECIFIC   INFECTIVE   DISEASES  107 

of  disease  is  slight,  and  should  never  be  employed  when 
fever  is  present,  when  signs  of  extensive  disease  are  to 
be  found,  and  when  the  heart  and  kidneys  are  not  quite 
sound. 

(3)  Von  Pirquet's  Cutaneous  Tuberculin  Reaction.  For 
this  purpose  a  50  per  cent,  solution  of  old  tuberculin  is  made 
in  normal  saline  :  two  separate  drops  of  this  are  placed  upon 
the  forearm  of  the  patient  ;  the  skin  is  now  scarified  through 
the  drops  just  as  in  ordinary  calf-lymph  vaccination.  After 
three  or  four  minutes  a  sterile  but  not  antispetic  dressing 
is  applied.  At  the  same  time  a  control  observation  is  made 
in  a  precisely  similar  manner  on  the  other  arm,  using  normal 
saline  instead  of  the  old  tuberculin.  On  both  arms  there 
will  be  seen  an  immediate  traumatic  reaction,  which  consists 
of  a  red  areola  surrounding  a  red  papule.  This  disappears 
in  about  twenty-four  hours  in  negative  cases,  but  if  ''the 
reaction  be  positive  there  is  a  definite  inflammatory  reaction 
in  the  one  arm  only  which  does  not  start  till  after  a  latent 
period  of  from  three  to  thirty-six  hours.  Ordinarily,  in  a 
positive  reaction,  there  is  a  well-marked  papule  surrounded 
by  a  red  areola  at  the  end  of  twenty-four  hours  ;  the 
reaction  reaches  its  height  in  about  forty-eight  hours  and 
then  gradually  fades. 

Jt  has  been  shown  that  a  positive  von  Pirquet  reaction 
occurs  both  in  cases  of  active  tuberculosis  and  also  in  cases 
where  the  k'sion  is  healed  ;  therefore  the  reaction  need  only 
signify  that  the  patient  has  had  tuberculosis  somewhere  at 
some  time.  The  reaction  is  not  obtained  in  cases  of  acute 
generalised  tuberculosis,  neither  is  it  always  present  m  cases 
of  tuberculous  peritonitis.  The  reaction  may  also  be  absent 
shortly  before  death. 

In  conclusion  we  may  say  that  a  positive  von  Pircpiet 
reaction  in  itself  can  never  determine  the  question  whether 
we  are  dealing  with  active  tuberculosis,  but  that  a  negative 
reaction,  as  indicating  freedom  from  tuberculosis,  may  be  of 
the  utmost  value 

(4)  Calmette's  Ophthalmo-Tuberculin  Reaction.  Two 
(li(»])s  of  a  ■.")  [wv  cent,  solution  of  old  tuberculin  in  distillcnl 
water  are  allowed  to  fall  into  the  conjunctival  sac  close 
to  the  inner  canthus  of  the  eye.     The  eyelids  should  be 


108  MEDICAL   DIAGNOSIS 

held  open  for  a  few  seconds  so  as  to  permit  of  the  circulation 
of  the  fluid.  A  positive  reaction  consists  of  a  distinct 
conjunctivitis  with  inflammation  of  the  caruncle.  The 
inflammation  reaches  its  maximum  in  from  twelve  to  eighteen 
hours,  after  which  time  it  gradually  subsides  and  has  usually 
complete^  disappeared  by  the  third  day.  In  non-tubercu- 
lous people  there  is  sometimes  a  slight  reddening  of  the 
conjunctiva  for  two  or  three  hours  after  the  instillation. 
The  test  must  never  be  employed  unless  the  eye  is  absolutely 
healthy  to  start  with. 

The  diagnostic  scope  of  the  reaction  is  identical  with  that 
of  the  von  Pirquet,  but  it  is  scarcely  so  safe  a  procedure  as 
this  latter. 

(5)  Moro's  Inunction  Tests.  The  ointment  used  consists 
of  equal  parts  of  old  tuberculin  and  anhydrous  lanoline.  A 
piece  of  ointment  the  size  of  a  pea  is  rubbed  lightly  into  the 
skin  of  the  chest  or  abdomen  over  an  area  of  a  few  square 
inches.  A  positive  reaction  is  indicated  by  the  appearance 
on  the  second  day  of  smaU  red  papules  at  the  site  of  inunction. 

(6)  Diagnosis  by  the  Determination  of  the  Opsonic  Index. 
The  researches  of  Wright  and  Douglas  tend  to  show  that 
there  is  circulating  in  the  blood  serum  a  substance  called 
"  Opsonin,"  the  function  of  which  is  to  react  upon  any 
micro-organisms  that  may  be  present  in  such  a  manner  as  to 
make  them  more  susceptible  to  the  phagocytic  action  of  the 
leucocytes.  It  is  probable  that  there  are  not  an  indefinite 
number  of  specific  opsonins  to  correspond  with  everj^  different 
variety  of  bacillus,  but  that  there  is  normally  present  a 
single  substance  which  can  be  activated  by  different 
bacilli  to  form  the  specific  opsonin  which  is  indicated. 

The  opsonic  index  is  the  ratio  between  the  opsonin  content 
of  the  blood  of  a  suspected  person  with  that  of  the  blood  of  a 
healthy  person.  The  required  ratio  is  determined  practically 
by  mixing  together  in  a  capillary  pipette  equal  volumes  of 
washed  leucocj'tes,  emulsion  of  tlie  required  bacilli,  and  the 
suspected  serum.  A  similar  procedure  is  adopted  in  another 
pipette,  substituting  healthy  for  the  suspected  serum.  Both 
pipettes  are  now  inoculated  at  37°  C.  for  fifteen  minutes,  in 
order  to  permit  the  opsonin  present  in  each  tube  to  sensitise 
as  many  bacilli  as  possible. 


SPECIFIC   INFECTIVE   DISEASES  109 

Films  are  then  spread  in  the  ordinary  manner  {vide  p.  155) 
and  stained  by  the  method  appropriate  to  the  micro 
organism  that  is  being  investigated.  The  films  are  now 
examined  with  an  oil  immersion  lens  and  the  number  of 
bacilli  counted  which  are  contained  in  one  hundred  leucocytes. 
This  number  in  the  case  of  the  healthy  serum  is  taken  as 
unity  ;  the  opsonic  index  of  the  suspected  person  is  therefore 
the  number  of  baciUi  contained  in  the  hundred  cells  from  the 
pipette  containing  the  suspected  serum  divided  by  the 
number  contained  in  the  hundred  cells  from  the  control. 

It  is  necessary  to  allow  a  considerable  margin  of  error  due 
to  the  technical  difficulties  in  estimating  an  opsonic  index  ; 
and  it  is  customary  to  consider  any  index  between  '8  and  r2 
as  being  normal.  A  low  opsonic  index  must  be  considered 
as  suggestive  of  disease,  especially  of  locahsed  tuberculosis 
such  as  lupus  or  arthritis,  but  at  the  same  time  a  persistently 
high  index  is  quite  compatible  with  an  active  infection  to 
which  there  is  a  pronounced  reaction. 

For  the  purposes  of  diagnosis  it  is  advisable  to  make  at 
least  two  determinations  of  the  opsonic  index,  one  before 
exercise  (the  amount  of  which  must  vary  with  the  condition 
of  the  patient)  and  one  immediately  after,  or  in  the  case  of 
locahsed  lesions,  such  as  joint  affections  or  tuberculous 
peritonitis,  one  before  massage  of  the  affected  parts  and  one 
immediately  after.  It  is  best  to  have  a  third  observation, 
viz.,  after  two  hours'  complete  rest,  following  immediately 
on  the  exercise  taken. 

If  the  patient  is  so  ill  as  to  render  exercise  out  of  the 
question,  one  determination  may  be  made  when  the  tempera- 
ture is  at  its  maximum  and  another  when  it  is  at  its  minimum. 
A  wide  variation  between  the  two  readings  obtained  as  above 
outlined  is  very  suggestive  of  a  tuberculous  infection. 

Another  method  is  to  take  the  opsonic  index  at  intervals 
of  three  or  four  hours  for  a  period  of  two  days,  making  also 
control  observations  with  a  healthy  serum.  It  will  be  found 
that  there  will  be  verj-  much  greater  variations  in  the  indices 
of  a  tuberculous  person  than  of  a  healthy  one,  a  fact  which 
can  readily  be  shown  by  plotting  the  two  series  of  observa- 
tions in  curve  form  on  the  same  chart. 

il)  The  Therapeutic  Method  of  Diagnosis.     This  method  is 


110  MEDICAL   DIAGNOSIS 

applicable  to  those  cases  in  which  there  are  no  objective 
signs  of  disease,  but  the  patient  feels  ill,  is  losing  weight,  and 
has  a  persistent  daily  rise  of  temperature  in  spite  of  pro- 
longed rest  and  other  forms  of  treatment. 

Therapeutic  doses  of  tuberculin  T.R.  are  administered 
either  by  the  mouth  or  by  subcutaneous  injection.  A  good 
initial  dose  is  soaooo  mgm.  The  dose  is  gradually  increased 
having  due  regard  to  the  temperature  chart,  that  dose  being 
desired  at  each  injection  which  is  sufficiently  small  to  avoid  a 
marked  negative  phase  (as  shown  by  a  rise  in  temperature 
immediately  following  the  injection)  and  yet  large  enough 
to  ensure  a  distinct  and  prolonged  positive  phase  (as  shown 
by  the  subsequent  flattening  and  lowering  of  the  tempera- 
ture). If  at  the  end  of  some  weeks  of  such  treatment  the 
temperature  is  permanently  flat  and  at  the  same  time  the 
patient  feels  better  and  is  gaining  weight,  then  assuredly  a 
positive  diagnosis  of  tuberculosis  is  justifiable. 

Summary  of  the  Diagnosis  of  Tuberculous  Disease.  When 
there  are  obvious  physical  signs  supplemented  by  the  presence 
of  tubercle  bacilli  the  diagnosis  is  simple.  In  the  absence  of 
tubercle  bacilli,  as  shown  by  repeated  examinations,  the  only 
certain  evidence  we  have  of  the  presence  of  active  tubercu- 
losis is  fluctuations  of  the  opsonic  index,  and  as  the  estima- 
tion of  this  is  difficult  it  cannot  be  relied  upon  as  a  general 
rule  in  ordinary  practice.  Other  tests,  such  as  the  various 
tuberculin  tests  or  examination  with  X-rays,  may  show 
evidence  of  tuberculosis,  but  give  no  answer  to  the  question 
whether  it  is  active  or  quiescent — that  is  to  say,  whether  the 
patient  requires  treatment.  In  the  great  majority  of 
doubtful  cases  we  have  evidence  of  toxaemia  such  as  slight 
fever,  best  shown  by  the  rectal  temperature,  or  a  raised 
temperature  after  exertion  which  does  not  return  to  the  normal 
after  half  an  hour's  rest,  night  sweats,  loss  of  appetite  and 
weight,  easy  fatigue,  and  loss  of  energy,  etc.  If  we  are  able  to 
exclude  toxaemias  of  other  origin,  such  as  occur  in  pyorrhoea, 
chronic  appendicitis,  etc.,  the  probability  that  we  are  dealing 
with  early  tuberculosis  is  great,  in  view  of  the  wide  distri- 
bution of  the  disease.  A  tuberculin  test  or  the  use  of  X-rays 
may  increase  our  suspicions.  The  history  of  the  case  may  do 
the  same — for  example,  in  pulmonary  disease  a  history  of 


SPECIFIC   INFECTIVE   DISEASES  111 

previous  pleurisy  a  few  months  or  years  ago  or  of  an  attack 
of  haemoptysis  makes  the  diagnosis  in  association  with  the 
symptoms  described  almost  certain.  In  many  cases  it  is 
necessary  to  keep  the  patient  under  observation  for  some 
weeks  and  then  come  to  a  conclusion  on  the  basis  of  clinical 
observation  and  laboratory  examinations.  The  diagnosis 
here  cannot  always  be  proved,  but  is  a  verdict  based  on 
circumstantial  evidence. 

XXIII.   TYPHUS. 

Definition.  An  acute  infective  disease  characterised  bj^ 
sudden  onset,  macular  eruption,  and  great  prostration,  and 
terminating  by  crisis. 

Bacteriology.  No  specific  micro-organism  has  been  identi- 
fied, but  there  is  evidence  to  suggest  that  the  contagio;i  is 
spread  through  the  medium  of  the  pediculus  corporis. 
Incubation  Period.  About  twelve  days. 
Course.  Occasionally  there  is  slight  malaise  for  a  few 
days,  but  usually  the  onset  is  abrupt,  with  rigor,  headache, 
and  pains  in  the  back  and  legs.  The  temperature  rises 
abruptly  to  103'  or  104°,  though  it  not  infrequently  attains 
its  maximum  on  the  fourth  day.  Prostration  is  early  and 
severe.  The  pulse  is  rapid  ;  at  first  full  and  bounding, 
towards  the  end  of  the  first  week  it  becomes  soft  and  feeble. 
Persistent  vomiting  is  a  distressing  feature. 

On  the  fourth  or  fifth  day  delirium  supervenes,  and  on 
the  fifth  day  the  characteristic  rash  appears.  This  consists 
of  two  elements — a  dusky  red  subcuticular  mottling  and 
distinct  rose-red  papules,  which  soon  become  the  site  of 
petechial  haemorrhages.  The  rash  appears  first  on  the 
abdomen  and  upper  part  of  the  wrists  ;  the  face  often 
escapes,  but  in  the  course  of  two  days  the  rest  of  the  body  is 
covered.  During  the  second  week  the  .symptoms  are 
intensified  though  the  lieadache  often  disappears. 

On  or  about  the  fourteenth  day  the  temperature  falls  by 
crisis  and  convalescence  ensues. 

There  is  usually  a  slight  leucocytosis, 
Complications.     The  most   important   complications   are 
broncho-pneumonia,  lobar  pneumonia  and  hypostatic  con- 
gestion  of   the   lungs.     Suppression  of   urine   and   uraMuia 


112 


MEDICAL  DIAGNOSIS 


may  prove  rapidly  fatal,  while  bed-sores  and  thrombosis, 
both  venous  and  arterial,  are  by  no  means  uncommon. 

Diagnosis.  Typhus  fever  is  now  of  such  rare  occurrence 
in  this  country  that  the  history  of  an  epidemic  or  of  exposure 
to  infection  is  of  paramount  importance.  Otherwise  the 
diagnosis  must  depend  on  the  sudden  onset,  the  rise  of  the 


1 

1 

1 

lOS' 
105' 
10*' 
103° 
102' 
101' 
100° 
99° 
98° 
9/' 
96' 
^.95° 
IfO 
130 
120 
no 
100 
90 

ao 

70 
60 

rso 
ss 

45 
35 
25 

M    E 

M   E 

M  e 

M   E 

M    E 

M  E 

M  E 

M  E 

M   E 

M   E 

M   E 

M  a 

M  E 

ME 

M  E 

M  E 

'  f 

/^ 

/' 

: 

I/'' 

s/ 

^ 

^ 

.A 

,'^ 

/ 

^ 

V^ 

\/' 

1,  A 

/ 

M 

1  : 

V^ 

"T" 

.-• 

.m. 

... 

•^« 

•»• 

... 

... 

... 

... 

.■i» 

■r» 

.m. 

•W' 

'l'^ 

"V 

: 

• 

■ 

; 

:  r 

r 

^ 

^. 

A 

A 

V- 

y 

^ 

■^ 

--^'\ 

\A 

P 

\ 

^; 

v>\ 

v; 

Va 

: 

N 

"T" 

•-• 

•-■ 

•  *. 

.  •" 

■ 

•  *. 

■  *■ 

•*• 

•T" 

■^- 

••• 

••■ 

a*. 

y 

'"N 

'■■^ 

''^ 

^^ 

A 

1^ 

V 

■-^ 

■v^ 

\^ 

""^ 

'■ 

: 

^_ 

_;_ 

_t; 

"^ 

Fio.  28. — Chart  from  a  case  of  Typhus  Fever  showing 
termination  by  crisis  on  the  fourteenth  day. 

temperature,  the  appearance  on  the  fifth  day  of  the  character- 
istic eruption,  and  the  termination  by  crisis. 

Typhus  must  be  differentiated  from  : — 

(i.)  Enteric  Fever.  In  enteric  fever  the  onset  is  gradual  ; 
there  is  often  diarrhoea  ;  the  rash  appears  later  (seventh 
day)  and  in  successive  crops,  it  is  limited  in  distribution, 
and  does  not  become  petechial,  whilst  subcuticular  mottling 
is  very  rare.     Early  prostration  is  not  so   marked  as    in 


SPECIFIC  INFECTIVE   DISEASES  IVS 

typhus,  whilst  the  termination  is  by  lysis  and  not  by  crisis, 
and  a  leucopenia  is  the  rule. 

At  the  end  of  the  first  week  Widal's  reaction  will  settle 
the  diagnosis. 

(ii.)  Measles.  In  measles  there  is  well-marked  coryza  ; 
the  rash  appears  on  the  fourth  day,  and  is  first  seen  on  the 
face.  The  temperature  begins  to  fall  on  the  sixth  day  and 
the  severe  prostration  of  typhus  is  absent  throughout. 

(iii.)  Small-pox.  Malignant  small-pox,  or  purpura  vario- 
losa, may  resemble  severe  typhus,  but  the  greater  extent  of 
the  haemorrhages  and  the  severe  bleeding  from  mucous 
membranes  should  prevent  mistake  for  more  than  a  few 
days. 

XXIV.  WHOOPING-COUGH. 

Definition.  A  specific  infective  disease  characterised  by 
respiratory  catarrh  and  paroxysms  of  coughing  which 
terminate  in  a  characteristic  whoop. 

Bacteriology.  The  causative  organism  has  only  recently 
been  isolated  (Bordct). 

Incubation  Period.     Usually  from  seven  to  fourteen  days. 

Course,  (i.)  The  Catarrhal  Stage.  The  initial  symptoms 
are  usually  those  of  an  ordinary  cold.  Bronchitis  is  present 
to  a  variable  extent,  but  in  the  majority  of  cases  there  is  a 
troublesome  and  persistent  cough.  In  from  ten  days  to  a 
fortnight  the  paroxysmal  stage  is  commenced. 

(ii.)  The  Paroxysmal  Stage.  The  cough  instead  of  abating 
becomes  more  severe  and  tends  to  assume  a  defuiitely 
convulsive  character.  Each  paroxysm  consists  of  froui 
fifteen  to  twenty  consecutive  short  coughs,  between  which 
no  inspiration  is  possible  ;  finally,  when  the  child  is  more 
or  less  deeply  cyanosed  there  is  a  deep  inspiration,  the  noise 
of  which  causes  the  characteristic  whoop. 

At  the  end  of  each  paroxysm  a  small  quantity  of  tenacious 
mucus  is  expectorated.     Not  infrequently  there  is  vomiting. 

The  paroxysms  vary  in  frequency  from  two  or  three 
to  fifty  or  sixty  in  the  day.  The  child  is  conscious  that  a 
paroxysm  is  imminent  and  displays  considerable  alarm, 
usually  running  to  its  nurse  or  mother  for  support. 

M.D,  8 


114  MEDICAL   DIAGNOSIS 

In  severe  cases  the  strain  of  the  coughing  causes  puffy 
swelhngs  to  appear  about  the  face  and  eyes.  There  is 
definite  leucocytosis  (sometimes  up  to  50,000),  with  eosino- 
philia  and  marked  relative  lymphocytosis. 

In  from  four  to  six  weeks  the  paroxysmal  stage  is  over  and 
convalescence  is  usually  rapid. 

Complications,  (i.)  Hcemorrhage.  There  is  extreme 
venous  congestion  as  the  result  of  the  coughing.  Small 
subcutaneous  haemorrhages  may  be  met  with,  particularly 
about  the  forehead.  Subconjunctival  ecchymoses  and  epis- 
taxis  are  common.  In  rare  cases  sub-dural  or  intra-cerebral 
haemorrhage  may  occur  ;  if  these  latter  do  not  cause  death, 
paralysis,  usually  a  hemiplegia,  may  result, 

(ii.)  Co7ivulsions.  The  extreme  cerebral  congestion  may 
give  rise  to  convulsions.  Not  infrequently  in  babies  spasm 
of  the  glottis  may  prevent  the  child  making  the  necessary 
inspiratory  effort  at  the  close  of  a  paroxysm  ;  it  rapidly 
becomes  black  in  the  face,  and  death  will  occur  if  someone 
is  not  at  hand  to  plunge  it  into  a  warm  bath  or  perform 
artificial  respiration. 

(iii.)  Respiratory  Complications.  Broncho-pneumonia  is 
a  very  frequent  complication  of  whooping-cough,  and  is 
responsible  for  a  large  number  of  deaths  in  the  first  few 
years  of  life. 

Interstitial  emphysema,  true  pulmonary  emphysema,  or 
even  pneumo-thorax  may  result  from  the  strain  of  coughing. 
Acute  bronchiectasis  (the  honeycomb  lung  of  childhood) 
may  complicate  or  follow  whooping-cough.  Pulmonary 
tuberculosis,  usually  of  the  broncho-pneumonic  type,  is  a 
not  infrequent  sequel. 

Enlargement  of  the  bronchial  glands  may  be  so  great 
as  to  give  rise  to  an  area  of  percussion-dulness  over  the 
manubrium.  In  adults  whooping-cough  is  sometimes  fol- 
lowed by  periodic  attacks  of  bronchial  asthma. 

(iv.)  Renal  Complications  are  rare,  but  the  urine  is  often 
diminished  in  amount  and  may  contain  albumin,  sugar, 
and  excess  of  acid. 

Diagnosis.  Though  adults  are  not  exempt,  whooping- 
cough  is  specially  a  disease  of  young  children.  History 
of  exposure   to  infection  is  of  course  important.     If  the 


SPECIFIC   INFECTIVE   DISEASES  115 

characteristic  whoop  is  heard,  the  diagnosis  is  certain, 
but  the  whoop  is  sometimes  absent,  more  especially  in 
adults.  The  diagnosis  then  rests  upon  the  paroxysmal 
nature  of  the  attacks  of  coughing,  especialh^  if  these  are 
followed  by  vomiting.  In  such  cases  a  marked  lymphoc}^- 
tosis  with  eosinophilia  proves  of  diagnostic  value. 

The  puffy  face,  especially  if  albuminuria  is  present, 
may  lead  to  a  diagnosis  of  acute  nephritis,  but  the  absence 
of  casts  and  the  presence  of  a  paroxysmal  cough  should 
prevent  this  error. 


8—2 


CHAPTER  II 

TROPICAL  disp:ases 

I.  BERI-BERI. 

Beri-beei  is  a  specific  form  of  polyneuritis  in  which  there 
is  a  special  tendency  for  the  involvement  of  the  phrenic  and 
vagus  nerves,  and  also  for  the  occurrence  of  oedema  and 
serous  effusions. 

The  incidence  of  beri-beri  is  practically  limited  to  the 
areas  between  45°  N.  and  35°  S.  (Manson). 

All  races  seem  liable  to  contract  beri-beri,  and  the  sexes 
are  equally  affected.  Europeans,  however,  and  children 
generally  escape. 

The  nature  of  the  poison  which  causes  beri-beri  is  unknown. 
It  can  be  conveyed  by  man  from  place  to  place,  but  probably 
is  not  infectious  from  case  to  case.  It  has  been  suggested 
that  beri-beri  is  contracted  by  eating  rice  which  has  been 
husked  without  preliminary  steaming,  but  the  evidence  in 
favour  of  this  view  is  far  from  conclusive. 

The  average  time  at  which  symptoms  appear  after 
commencing  to  reside  in  a  beri-beri  infected  building  {e.g.,  a 
prison)  is  three  to  four  months. 

The  first  conspicuous  symptoms  are  those  of  peripheral 
neuritis  {vide  p.  508),  but  there  are  often  (though  not  always) 
premonitory  symptoms  for  some  weeks,  such  as  headache, 
lassitude,  cramp,  numbness,  and  tingling. 

The  neuritis  affects  the  legs  and  arms  at  first,  and  is  soon 
accompanied  by  oedema  of  the  ankles,  hands  and  face. 
Breathlessness,  palpitations,  sub -sternal  oppression  and 
tachycardia  indicate  involvement  of  the  vagus  nerve.  The 
diaphragm  may  act  feebly  or  not  at  all  if  the  phrenic  is 
affected.  After  several  weeks  the  oedema  disappears, 
and  it  is  then  obvious  that  extreme  wasting  has  occurred. 
Convalescence  is  very  protracted  and  tedious.  Relapses 
are  not  uncommon. 


TROPICAL   DISEASES  117 

All  grades  of  severity  may  occur.  In  the  worst  forms. a 
bilateral  vagus  neuritis  may  cause  death  in  a  few  hours  ; 
in  the  milder  form  there  is  only  slight  loss  of  power  and 
trifling  oedema  of  the  shins. 

There  is  never  any  mental  impairment. 

Two  main  classes  are  distinguished  clinically  : — 

(i.)  The  dry  or  atrophic  form,  in  which  the  neuritic 
atrophy  is  very  pronounced  and  the  oedematous  symptoms 
are  relatively  slight. 

(ii.)  The  ivet  or  cedetnafoiis  form,  in  which  the  atrophy  is 
relatively  slight  or  is  masked  by  the  very  prominent  oedema, 
with  which  are  associated  effusions  into  the  serous  mem- 
branes. 

The  mortality  is  considerably  higher  in  the  wet  form  than 
in  the  dry,  and  also  varies  with  different  epidemics.  It  is 
highest  at  the  beginning  of  an  epidemic,  and  in  all  is  less 
than  10  per  cent. 

The  diagnosis  depends  on  the  association  of  peripheral 
neuritis  with  oedema.  There  can  be  little  difficulty  in  the 
case  of  an  epidemic,  which  could  only  be  simulated  by  chronic 
arsenical  poisoning  from  adulterated  food  or  drink.  The 
characteristic  cutaneous  and  gastro-intestinal  symptoms  of 
chronic  arsenical  poisoning  are  not  seen  in  beri-beri. 

Isolated  cases  of  beriberi  may  present  considerable 
difficulty  in  diagnosis  if  they  are  of  the  dry  form.  The 
type  of  neuritis  may  exactly  simulate  the  ataxic  form  of 
alcoholic  neuritis,  but  there  is  no  mental  change. 

Reliance  must  be  placed  on  the  possible  history  of  alcohol 
and  evidence  of  the  vagus  or  phrenic  nerves  being  involved. 
Qiidema,  to  a  greater  extent  than  a  slight  puflfiness  of  the 
shins,  is  in  favour  of  beri-beri. 

II.  CHOLERA. 

A  specific  infective  disease  characterised  by  \omiting, 
purging,  muscular  cramps,  and  suppression  of  urine. 
Cholera  is  endemic  in  certain  parts  of  Asia,  but  is  also  liable 
to  occur  in  widespread  epidemics. 

Bacteriology.  The  bacillus  of  cholera  was  di.scovered  by 
Koch  in  iss.'i.  It  is  a  small,  comma-shaped  vibrio,  some- 
times  a.ssuming   a  complete  spirillum  form.      It  is  highly 


118  MEDICAL  DIAGNOSIS 

motile,  flagellated,  and  does  not  form  spores.  It  grows  well 
on  ordinary  media  ;  on  gelatine  plates  at  22°  C.  small 
yellowish-white  highly  refractile  colonies  with  scalloped  edges 
develop  in  twenty-one  hours.  Eventually  the  gelatine 
liquefies  and  the  colonies  sink  into  its  substance.  In 
dilute  peptone  the  vibrios  grow  on  the  surface  as  a  pellicle. 
Preferably  a  faintly-alkaline  medium  should  be  used  for  the 
cultivation  of  the  cholera  bacillus. 

The  vibrio  stains  well  with  ordinary  dyes  (dilute  carbol- 
fuchsin  is  the  best)  and  is  Gram-negative.      It  possesses 

the  property  of  becoming 

^-'"'^j     T*vii    X,  agglutinated  b  3^  a  specific 

*,_       i      ^    ^-Xi  cholera     serum.       Agglu- 

\  ^  ^  ^  tination     within     twenty 

'  *     ''  ^     ^    <    ^        \   "        minutes     by     a     serum 

'_    'I)    N^    ''^    {  ''     '' .    1'  />~\      diluted    500    times    with 

•  vv  'V, ,  "^         ^     normal  saline  is  considered 

c      ""    V^-o  ^  »    \,         '  positive.     This  test  is  per- 

\    --  *=    ^'^X  '      ''     formed    in   a  converse 

•^      ^  ^     ^       V  '      ^      ^  '       manner     to     the     Widal 

A         .  *_^   ]^y\  reaction  (cf.  p.   20)— that 

N      ->>^  «  is  to  say,  peptone  cultures 

'"  .♦         ,N  are  made  from  the  dejecta 

Fig.  29.— SplriUum  of  Cholera  from  Agar  of  ^  suspected  patient  and 
culture,  48  hours.  Magnification  >;  a  fragment  of  a  colony 
1000 

obtained  by  sub-culture  is 

added   to    the   diluted  specific  cholera  serum,    which    only 

agglutinates  true  cholera  vibrios. 

In  the  very  great  majority  of  cases  infection  occurs  through 
water  which  is  used  for  cooking  or  drinking  or  washing 
utensils  and  which  has  been  contaminated  by  dejecta  from 
cholera  patients. 

As  far  as  is  known  the  infective  material  must  be 
swallowed. 

Incubation  Period.  The  incubation  period  of  cholera  is 
probabl^^  two  to  five  days. 

Course.  Individual  cases  vary  greatly  in  severity  as 
do  different  epidemics.  The  following  account  may  be 
regarded  as  an  average  case.      Four  stages  are  recognised  : — 

(i.)  Premonitory  Stage.       This  is  by  no   means   always 


TROPICAL   DISEASES  119 

present,  but,  if  it  occurs,  consists  in  gastro-intestinal  dis- 
turbance with  diarrhoea  of  varying  severity.  It  lasts  for  a 
few  hours  or  even  several  days. 

(ii.)  The  Evacuation  Stage.  This  may  be  the  first  sym- 
ptom, and  is  characterised  by  violent  purging,  with  the 
passage  of  copious  watery  stools  (rice-water  evacuations), 
vomiting,  cramps  in  the  calves  and  the  abdominal  muscles, 
and  exhaustion.  There  is  no  tenesmus.  Both  the  vomited 
matter  and  the  stools  may  be  flecked  with  blood  in  the 
later  stages.  The  cutaneous  temperature  becomes  sub- 
normal as  this  stage  proceeds,  but  the  rectal  temperature 
may  show  high  fever. 

The  average  duration  of  the  evacuation  stage  is  three  to 
twelve  hours. 

(iii.)  The  Collapse  Stage.  The  surface  is  cold  and  clammy  ; 
the  eyes  are  sunken  ;  the  voice  husky  or  even  lost  ;  the  pulse 
feeble  and  rapid  ;  and  the  urine  scanty,  albuminous,  or 
suppressed.  The  cramps  may  be  prolonged  into  this  st^ge, 
but  usually  cease,  as  do  the  profuse  evacuations.  This  stage 
lasts  from  three  to  forty-eight  hours. 

(iv.)  The  Stage  of  Reaction.  In  this  there  is  a  gradual 
restoration  of  the  functions,  the  pulse  returns  at  the  wrist, 
the  skin  becomes  warm,  and  urine  is  once  more  secreted  and 
the  motions  resume  their  foeculent  character.  In  favourable 
cases,  beyond  weakness,  there  may  be  no  adverse  symptoms 
after  three  days. 

In  a  proportion  of  cases,  however,  the  reactionary  stage 
only  proceeds  a  short  way  and  the  fatal  tepid  phase  is 
manifested,  in  which  the  temperature  remains  subnormal, 
vomiting  and  purging  continue  ;  the  patient  remains  semi- 
comatose, and  dies  of  exhaustion  in  a  few  hours. 

The  total  mortality  of  cholera  is  usually  given  as  50  per 
cent. 

The  following  atypical  forms  of  cholera  may  be  mentioned  : 

(a)  An  ambulatory  form,  in  which  the  disease  is  aborted 
in  the  premonitory  stage. 

(6)  A  form  in  which  the  second  stage  is  very  slight  and  the 
entire  trouble  is  over  in  twenty-four  hours  (cholerine). 

(c)  Very  occasionally  the  stage  of  collapse  is  reached  with- 
out the  preliminary  vomiting,  purging  or  cramps.     These 


120  MEDICAL   DIAGNOSIS 

cases  present  very  great  difficulties  in  diagnosis,  but  fortu- 
nately are  extremely  rare. 

(d)  Some  cases  show  ursemic  signs  from  prolonged  sup- 
pression of  urine  ;  a  fatal  issue  is  to  be  apprehended  in  this 
form. 

(e)  A  considerable  number  of  cases  end  fatally  from  pro- 
found toxaemia  in  a  few  hours,  even  before  the  evacuation 
stage  has  properly  developed. 

The  diagnosis  of  cholera  depends  upon  a  history  of  possible 
infection,  such  as  the  presence  of  a  local  epidemic,  etc.,  upon 
the  characteristic  features  of  the  disease  as  described  above, 
and  upon  the  discovery  of  the  specific  organism  in  the  stools. 

The  identity  of  the  vibrio  is  established  by  cultural 
characteristics  aided  b}^  the  agglutination  test  as  described 
above. 

Cholera  may  be  simulated  to  some  extent  by  food- 
poisoning  (especially  mushroom  poisoning),  by  malarial 
diarrhoea,  and  possibly  by  very  acute  bacillary  dysentery. 

Malaria  may  be  distinguished  by  its  reaction  to  quinine 
and  by  the  examination  of  the  blood  for  the  parasites  and  for 
leucocytosis.  (There  is  a  leucocytosis  in  cholera,  up  to 
30,000  to  50,000,  but  none  in  malaria  ;  further,  in  cholera 
there  is  polycythaemia). 

Dysentery  does  not  really  resemble  cholera  ;  it  may  be 
distinguished  by  the  character  of  the  motions,  the  passage 
of  blood,  the  tenesmus,  the  griping  pains,  and  the  absence  of 
muscular  cramps. 

Food  poisoning  may  be  suspected  from  the  history  of  a 
limited  number  of  persons  only  being  affected,  all  of  whom 
have  eaten  some  common  dish,  and  by  the  absence  of  the 
cholera  vibrio  in  the  dejecta. 

III.  DYSENTERY. 

Definiiion.  Anulcerative  infection  of  theintestinal  mucous 
membrane,  affecting,  as  a  rule,  the  lower  part  of  the  large  gut, 
but  often  involving  the  whole  colon  and  the  caecum  and 
sometimes  the  small  gut  also. 

The  ulcers  start  in  the  lymph  nodules  ;  they  spread  in  a 
most  irregular  manner,  depending  somewhat  on  the  severity 


TROPICAL  DISEASES  121 

of  the  infection,  and  are  often  connected  with  each  other  by 
sub -mucous  tracks. 

Bacteriology.  Two  forms  are  recognised — first  the  bacil- 
jary  type,  which  is  caused  by  Shiga's  Bacillus  dysentericus, 
and  secondly  the  amoebic  type,  which  depends  on  the  presence 
of  the  Amoeba  dysenteriaj  (Entamoeba  histolytica). 

Shiga's  bacillus  resembles  the  Bacillus  typhosus  rather 
closely,  except  that  it  is  not  so  slender,  is  very  slightly  if 
at  all  motile,  and  does  not  form  spores.  It  stains  well  with 
all  ordinary  stains  and  is  Gram-negative.  It  grows  fairly 
readily  on  ordinary  media,  and  can  be  separated  from  other 
organisms  if  a  plate  culture  is  made  from  the  suspected 
dejecta  and  subcultures  made  from  those  colonies  which 
appear  later  than  twelve  hours.  It  does  not  ferment  sugars, 
neither  does  it  form  gas  in  the  usual  media. 

Bacillary  dysentery  can  be  produced  by  organisms 
similar  to  but  not  identical  with  Shiga's  bacillus.  In- 
dividual epidemics  are  probably  due  to  one  partij?ular 
organism. 

The  scrum  of  dysenteric  patients  agglutinates  the  appro- 
priate  bacillus  in  dilutions  of  1  in  50  or  less. 

Bacillary  dysentery  is  the  epidemic  disease  which  afflicts 
armies,  caravans,  pilgrimages,  and  lunatic  asylums.  Spora- 
dic cases,  however,  are  not  infrequent.  Relapses  arc  uncom- 
mon, and  chronic  dysentery  is  comparatively  seldom  of  this 
type. 

Amoebic  dysentery  is  endemic  in  many  parts  of  the  East 
(such  as  the  Philippine  Islands)  ;  it  may  cause  illness 
almost  if  not  quite  as  severe  as  the  bacillary  form,  but  tends 
rather  to  produce  the  chronic  and  relapsing  variet}^  ;  indeed, 
a  fair  proportion  of  the  cases  are  sub -acute  or  chronic  from 
the  start. 

The  amoeba  of  dysentery  is  a  protozoon  about  30  /u,  in 
diameter  ;  it  consists  of  ectosarc,  endosarc,  and  granuhir 
protoplasm,  in  which  red  blood-cells  may  be  visible.  The 
ectosarc  is  highly  refractile.  There  is  a  nucleus  some 
5  or  0  ju,  ill  diameter,  but  this  is  difficult  to  see  while  the 
creature  is  alive.  The  amoeba  should  be  searched  for  in 
fresh  dejecta,  and  in  fragments  of  mucus,  not  in  portions  of 
faecal  matter.     The  slitle  must  be  examined  on  a  warm  stage 


122  MEDICAL  DTAGNOSIS 

in  a  wet  preparation,  and  should  not  be  identified  unless 
definite  pseudopodial  action  can  be  observed. 

Certain  amoebae  may  be  present  in  any  person's  colon, 
especially  after  a  dose  of  magnesium  sulphate.  These 
amoebae  coli  are  not  pathogenic  ;  they  are  smaller,  less 
ref  actile,  less  vacuolated,  and  less  active  than  the  Entamoeba 
histolytica.  Nevertheless,  considerable  experience  is  neces- 
sary to  differentiate  quickly  and  with  certainty  the  simple 
from  the  pathogenic  forms. 

The  symptoms  of  acute  dysentery,  whether  bacillary  or 
amoebic,  are  as  follows  : — 

Violent  purging,  with  the  passage  of  loose  motions  every 
few  minutes  till  all  fsecal  matter  is  expelled,  and  then  the 
equally  frequent  evacuation  of  blood  and  mucus,  usually  in 
small  quantities  at  a  time,  but  accompanied  by  severe 
tenesmus  and  also  griping  pains  in  the  abdomen,  due  to 
painful  contractions  and  spasm  of  the  colon. 

Vomiting  is  generally  absent.  Thirst  is  excessive  and  the 
other  signs  of  collapse  are  marked. 

There  is  usually  great  tenderness  to  palpation  along  the 
course  of  the  colon. 

Fever  is  usually  present  in  the  bacillary  form,  but  not  in 
the  amoebic.  The  onset  in  the  epidemic  form  may  be 
alarmingly  sudden,  but  in  the  milder  varieties  the  disease  is 
commonly  preceded  by  what  seems  at  fijst  to  be  a  mild 
diarrhoea. 

The  symptoms  of  chronic  dysentery  are  identical  with 
those  of  ulcerative  colitis  {vide  p.  367),  from  which  it  can  only 
be  distinguished  by  a  previous  history  of  dysentery  or  the 
recovery  of  the  amoeba  (or  rarely  the  bacillus)  from  the  stools. 

The  occurrence  of  a  liver  abscess  is  proof  of  amosbic 
dysentery. 

The  diagnosis  of  acute  dysentery  is  usually  easy.  Resi- 
dence in  the  tropics  or  under  conditions  favourable  to  an 
outbreak  are  important  points. 

The  recovery  of  the  specific  organism  is  conclusive,  as  is  a 
positive  agglutination  test. 

Enteric  fever  has  a  gradual  onset  (though  it  may  be  rela- 
tively quite  sudden  in  the  tropics)  ;  there  is  no  tenesmus 
and   blood   is    not    passed    for    many    days.      The    Widal 


TROPICAL   DISEASES  123 

reaction  and  the  cultivation  of  the  bacillus  from  the  blood 
are  conclusive. 

Cholera  has  copious  watery  motions,  cramps,  and  vomiting, 
but  neither  tenesmus  nor  the  passage  of  blood.  The  onset 
is  likely  to  be  even  more  sudden  than  in  acute  dysentery. 

Malaria  may  produce  a  variety  of  clinical  dysentery, 
but  the  malaria  parasite  can  be  demonstrated  in  the  blood  of 
patients  with  active  malaria,  though,  if  a  patient  with 
active  malaria  contracted  dysentery  at  the  same  time,  the 
diagnosis  might  depend  on  the  agglutination  test  or  the 
presence  of  the  dysentery  organism.  At  the  same  time, 
for  malaria  to  simulate  dysentery  is  relatively  uncommon. 

IV.  KALA-AZAR  (Dum-Dum  Fever). 

Kala-Azar  is  a  febrile  disease  characterised  by  progressive 
enlargement  of  the  spleen,  extreme  emaciation,  and  a  ten- 
dency to  dropsical  effusions. 

The  cause  is  believed  to  be  one  of  the  "  flagellata," /the 
Leishman-Donovan  body,  which  can  be  recovered  from  the 
spleen  of  patients  and  also  from  the  blood  and  other  organs  ; 
they  are  minute  ovoid  bodies  (2" 5  ^  in  diameter)  with 
vacuolated  protoplasm  and  two  distinct  nuclear  masses. 
When  cultivated  in  vitro  these  bodies  can  be  seen  to  develop 
in  six  days  into  typical  flagellates. 

Kala-azar  is  most  prevalent  in  Assam,  but  also  occurs 
in  China,  India,  Burma,  Egypt,  and  Algiers.  It  can  be 
communicated  by  human  intercourse,  but  how  this  occurs 
is  not  known,  though  it  is  suggested  that  the  bed-bug 
may  be  the  medium. 

Clinical  Features.  Kala-azar  is  a  very  chronic  disease, 
and  its  earliest  manifestations  are  not  fully  described. 
Probably  the  first  sign  is  fever,  which  may  be  either  inter- 
mittent or  remittent,  and  which  lasts  from  two  to  six  weeks. 
During  this  fever  the  spleen  and  liver  enlarge. 

After  a  period  of  remission  there  is  another  febrile  attack, 
and  after  this  a  shorter  remission,  till  at  last  there  is  con- 
tinuous pyrexia  of  remittent  type. 

After  the  first  attack  the  enlargement  of  the  spleen  and 
liver  disappears,  but  after  several  bouts  of  fever  the  enlarge- 
ment is  })ermanent. 


124  MEDICAL   DIAGNOSIS 

The  period  of  continued  fever  lasts  about  nine  or  ten 
months  and  is  succeeded  by  a  phase  of  cachexia,  often  with 
a  subnormal  temperature  and  dropsical  effusions,  which  con- 
tinues until  death  takes  place,  usually  from  some  inter- 
current malady. 

Some  cases  terminate  fatally  in  a  few  months,  others 
last  for  about  two  years.     The  mortality  is  over  90  per  cent. 

An  important  feature  of  kala-azar  is  the  tendency  for 
haemorrhages  from  mucous  surfaces  and  under  the  skin. 

The  blood  picture  is  striking  ;  there  is  a  slight  anaemia, 
with  a  colour  index  rather  below  unity,  and  also  there  is  a 
very  marked  leucopenia  (2,000  or  less),  with  which,  however 
a.  relative  lymphocytosis  can  be  recognised. 

The  diagnosis  depends  upon  the  history  of  the  febrile 
attacks,with  haemorrhages  and  transient  oedemas  as  described 
above,  the  large  spleen  and  liver,  the  characteristic  blood 
picture,  the  absence  of  the  malaria  parasite  from  the  blood, 
and  the  demonstration  of  the  Leishman-Donovan  bodies 
in  the  material  derived  from  splenic  or  hepatic  puncture. 

Leishman  lays  stress  on  the  importance  of  slightly  stirring 
up  the  splenic  tissue  with  the  needle  point  to  break  up  some 
of  the  cells  and  permit  the  escape  of  the  parasite  into  the 
blood  before  withdrawing  it  into  the  syringe  ;  the  same 
authority  considers  that  hepatic  puncture  is  preferable 
to  splenic  puncture  as  being  less  dangerous. 

V.  LEPROSY. 

Leprosy  is  a  disease  characterised  by  the  formation  of 
granulomatous  masses  in  the  skin,  mucous  membranes,  and 
nerves.  It  is  a  specific  infection  and  is  due  to  the  Bacillus 
leprae.  It  may  be  met  with  all  over  the  world,  but  is 
especially  prevalent  in  Asia.  It  flourished  throughout 
Europe  in  the  Middle  Ages. 

Bacteriology.  The  bacillus  of  leprosy  closely  resembles  the 
tubercle  bacillus  in  appearance  and  in  staining  reactions  ;  it 
has  not  been  cultivated  outside  the  body,  and  recent  claims 
that  this  has  been  accomplished  still  lack  confirmation. 

The  organism  is  present  in  large  numbers  in  the  skin  of 
leprous  nodules  and  in  the  discharges  from  ulcerative  lesions. 


TROPICAL  DISEASES  125 

Leprosy  is  presumed  to  be  contagious,  but  very  prolonged 
contact  and  a  suitable  "  soil  "  are  probably  necessary. 

Artificial  inoculation  experiments  have  scarcely  ever  been 
unequivocally  successful,  and  the  lower  animals  appear  to 
be  immune. 

Incubation  Period.  The  incubation  period  is  necessarily 
very  uncertain  ;  many  years  may  elapse  after  leaving  a 
leprosy  district  before  the  disease  becomes  apparent. 

Course.  The  patient  is  liable  to  vague  pains  and  inde- 
finite febrile  attacks  for  several  months,  or  even  years, 
before  any  objective  signs  appear. 

Clinically  the  earliest  signs  are  a  succession  of  erythema- 
tous spots,  which  are  often  pigmented  and  are  particularly 
prone  to  appear  on  the  ears,  nose,  forehead,  forearms, 
and  the  backs  of  the  hands  ;  at  first  these  patches  are  hyper- 
sesthetic  and  are  transient,  but  later  some  of  them  tend  to 
become  permanent  anaesthetic  macules.  Some  of  these 
lose  their  pigment  and  become  peculiarly  white  and  shj.ny. 

The  next  phenomenon  is  usualh''  the  development  of 
granulomatous  nodules  in  the  skin,  mucous  membranes, 
and  nerves.  These  tend  to  appear  first  in  the  regions 
where  the  macular  eruption  has  been  ;  later  ulceration 
may  occur,  with  considerable  tissue  loss. 

The  last  stage  ma}'  be  divided  clinically  into  three  groups  ; 

(i.)  The  nodular  variety  (which,  indeed,  may  develop 
without  any  preceding  macular  stage),  in  which  hard, 
flat,  subcutaneous  nodules  appear  in  the  skin,  especially 
about  the  face,  ears,  and  forearms.  This  form  causes  the 
"  leonine  "  aspect  said  to  be  characteristic  of  leprosy. 

(ii.)  The  ancesthdic  variety  is  produced  by  an  extensive 
peripheral  neuritis,  due  to  the  local  action  of  the  bacilli 
on  the  nerves.  It  is  often,  but  not  always,  preceded  by 
a  macular  eruption,  but  this  is  often  best  marked  on  the 
abdomen,  back  and  buttocks,  and  is  not  so  characteristically 
distributed  over  the  face  and  ears  as  in  the  nodular  form. 
Anaesthesia,  muscular  atrophy,  bulla?,  ulceration,  gangi'ene 
and  contractions  are  the  features  of  this  variety. 

The  median,  ulnar,  radial,  anterior  tibial,  and  peroneal 
nerves  arc  the  first  to  be  atfccted,  and  are  thickened  and  in 
early  stages  tender  to  the  touch. 


126  MEDICAL  DIAGNOSIS 

(iii.)  The  mixed  variety  is  a  combination  of  the  other 
two  forms  ;  it  is  probable  that  most  cases  are  in  reaUty 
mixed,  though  in  any  given  case  one  type  may  largely 
predominate. 

The  diagnosis  may  be  difficult  in  the  macular  stage,  but 
the  tendency  to  central  anaesthesia  in  the  patches  and  the 
absence  of  perspiration  over  them  when  pilocarpine  has  been 
injected,  as  well  as  their  characteristic  distribution,  should 
prevent  mistake. 

In  the  later  forms  it  is  only  necessary  to  excise  a  portion 
of  a  nodule  or  a  fragment  of  nerve  in  an  anaesthetic  patch 
and  to  stain  sections  of  the  material  by  the  Ziehl-Neelson 
stain  as  for  tubercle  bacilli,  when  clumps  of  red,  beaded 
bacilli  can  be  shown  lying  between  the  cells  of  the  granulation 
tissue.  The  purely  anaesthetic  type  may  present  resem- 
blances to  syi-ingomyelia  (especially  Morvan's  type),  but 
the  history  of  preceding  macular  eruptions  and  the  thicken- 
ing of  the  nerves,  as  well  as  the  type  and  distribution  of  the 
sensory  disturbance,  should  suggest  the  diagnosis. 

VI.  MALARIA. 

Malaria  is  a  disease  characterised  by  the  occurrence  of 
febrile  attacks  which  may  be  periodic,  irregular,  or  con- 
tinuous, according  to  the  variety  of  the  causative  Plasmo- 
dium. In  all  cases  the  Plasmodium  enters  the  blood-stream 
of  the  patient  as  the  result  of  the  bite  of  a  mosquito 
(Culex  Anopheles).  Only  the  female  mosquito  conveys 
malaria,  and  she  only  bites  at  night. 

Varieties.     Three  types  of  malaria  are  recognised  : — 
(i.)  Tertian  fever,  caused   by  the    Plasmodium  vivax, 

and  characterised  by  the  onset  of  fever  every  forty-eight 

hours. 

(ii.)  Quartan  fever ,  caused  by  the  Plasmodium  malariae, 

and  characterised  by  the  onset  of  fever  every  seventy-two 

hours. 

(iii.)  JEiStivo-aulumnal  fever,  caused  by  the  Laverania 

malariae,    and   characterised   by    the    onset    of   fever    at 

irregular  intervals. 

Parasitology,  (i.)  The  Tertian  parasite  first  occurs  in  the 
red  blood  corpuscles  as  a  small  colourless  body  of  indefinite 


Fig.  30.-    Blodcl  Films  showino-  JNIalaria!  Pafasito?. 


(r/)  Bcnisn  'J'ertian 

[b)  (Quartan, 

[c\  Pviiiii-Forms  in  "'  Malit;iiant     Teitian  Fever. 

(d)  Crescents  in  "■  Maliiinant  "  Teitian  FeviT. 


TROPICAL  DISEASES  127 

shape.  In  a  few  hours  it  increases  in  size  and  develops 
granular  pigment.  In  twenty-four  hours  it  fills  the  corpuscle, 
which  is  swollen  and  bloated.  This  parasite  now  becomes 
either  a  sporocyte  or  a  gametocyte.  The  sporocytes 
undergo  segmentation  and  divide  b}^  radial  hues  into  from 
fifteen  to  thirty  spores.  The  corpuscle  now  bursts  and  the 
spores  are  liberated  into  the  circulation.  The  liberated 
spores  attack  fresh  red  corpuscles,  and  the  same  asexual 
cycle  is  gone  through  again  and  again. 

A  feature  of  the  development  of  those  young  spores  which 
are  not  going  to  assume  a  sexual  form  is  the  stage  of  vacuola- 
tion,  which  causes  a  characteristic  appearance  like  a  signet- 
ring.  The  gametocytes  differentiate  into  male  and  female 
forms,  but  cannot  undergo  sexual  reproduction  until  they 
have  been  withdrawn  from  the  human  host  by  a  mosquito. 

In  the  stomach  of  the  moscpiito  the  male  and  female 
gametocytes  escape  from  the  red  blood  corpuscles,  and  the 
male  gametocyte  detaches  from  itself  flagella-like  micro - 
gametes  which  enter  into  and  fertihse  the  female  gametocyte, 
which  is  now  called  a  zygote. 

The  zygote  becomes  capsulated,  penetrates  the  wall  of 
the  mosquito's  stomach,  and  discharges  large  numbers  of  thin 
spindle-shaped  sporozoites  into  the  blood-stream  of  the 
mosquito.  These  sporozoites  reach  the  salivary  glands  of 
the  insect  and  are  injected  into  the  blood  of  the  next  person 
bitten  by  the  mosquito. 

The  asexual  cycle  in  the  human  blood-stream  takes 
forty-eight  hours,  and  the  disruption  of  the  red  cells,  with 
the  liberation  of  swarms  of  spores,  coincides  with  the  occur- 
rence of  a  febrile  paroxysm. 

(ii.)  The  life  history  and  general  features  of  the  Quartan 
parasite  arc  similar  to  those  of  the  tertian  parasite,  with 
the  exception  that  it  has  a  more  definite  outline  and 
coarser  and  blacker  pigment,  causes  the  red  corpuscles  to 
shrink  rather  than  to  swell,  has  an  asexual  phase  of  set'C??^?/- 
tivo  hours,  and  only  forms  from  six  to  twelve  spores. 

(iii.)  The  A^stivo-autumnal  parasite  is  much  smaller  and 
less  pigmented  than  the  other  forms.  The  later  stages  of 
the  asexual  phase  cannot  be  observed  in  the  peripheral 
blood-stream,  since  they  are  carried  out   in  the  blood  of 


128  MEDICAL  DIAGNOSIS 

the  spleen  and  bone  marrow.  After  about  six  days,  however, 
sexual  forms  appear  in  the  peripheral  circulation  ;  these 
are  crescentic  or  sausage-shaped  bodies  with  pigment 
granules  ;  they  cannot  sporulate  in  their  human  host, 
but  readily  do  so  on  reaching  the  stomach  of  the  mosquito. 
Clinical  Features  of  Malaria,  (i.)  The  Tertian  Form. 
The  incubation  period — that  is  to  say,  the  interval  between 
infection  and  a  febrile  paroxysm — is  about  fourteen  days. 
This  depends  on  the  number  of  sporozoites  injected,  since 
it  will  take  a  considerable  time  for  sufficient  red  cells  to 
become  infected  to  discharge  enough  spores  into  the  circu- 
lation to  produce  a  definite  reactionary  fever.  There  may 
be  shght  general  malaise  for  two  to  three  days  before  a 
paroxysm. 

The  febrile  attacks  last  about  eleven  hours  and  are  divided 
into  three  stages  : — 

(a)  The  Cold  Stage.  This  is  accompanied  by  headache, 
lassitude,  giddiness,  yawning,  and  sometimes  sickness  ; 
after  a  few  premonitory  chills  a  severe  rigor  sets  in,  which 
lasts  up  to  an  hour. 

(6)  The  Hot  Stage.  The  temperature  rises  to  from  103° 
to  105°  F.  The  patient  feels  very  hot  and  complains 
bitterly  of  headache,  backache,  giddiness,  and  often  of 
tinnitus.  Delirium  is  not  infrequent.  The  spleen  may 
enlarge  rapidly.     The  hot  stage  lasts  four  or  five  hours. 

(c)  The  Sweating  Stage.     The  onset  of  profuse  perspira- 
tion brings  relief  of  the  symptoms  ;   the  temperature  falls 
steadily  and  is  subnormal  in  about  four  hours. 
In  forty-eight  hours  from  the  onset  of  the  cold  stage  the 
entire  process  is  gone   through   again  :    the  patient  feels 
quite  well  in  the  interval. 

If,  as  is  usually  the  case,  there  is  a  double  infection  with 
asexual  forms  maturing  at  different  times,  there  will  be  a 
daily  paroxysm  ;  careful  analysis  of  the  temperature  chart 
will  show  that  there  is  forty-eight  hours  interval  between 
the  alternate  paroxysms,  and  examination  of  the  blood 
shows  two  distinct  generations  of  parasites  at  different 
stages  of  development.  In  a  similar  way  multiple  tertian 
infections  can  be  diagnosed. 

(ii.)  The  Quartan  Form.     This  is  much  rarer  than  the 


TROPICAL  DISEASES  129 

tertian.  The  paroxysms  occur  every  seventy-two  hours, 
unless  there  is  a  double  infection,  when  there  is  a  paroxysm 
for  two  successive  days  and  then  a  free  day.  Of  course  a 
triple  quartan  infection  gives  a  paroxysm  every  day.  The 
individual  paroxysms  are  in  all  respects  similar  to  those 
described  as  occurring  in  the  tertian  form. 

Repeated  attacks  of  tertian  or  quartan  fever,  if  untreated, 
may  result  in  grave  cachexia  ;  as  a  rule,  however,  spon- 
taneous recovery  takes  place. 

(iii.)  The  ^stivo-Autumnal  Form.  This  variety  is 
especially  met  with  in  the  real  tropics.  The  tendency  is 
for  a  continuous  remittent  fever  to  develop,  which  may  be 
explained  by  the  prev^alence  of  multiple  infections  and  also 
by  the  arrangement  of  the  parasites  in  groups  Avith  a  long 
period  of  segmentation. 

The  simple  cycle  of  asexual  dev^elopment  of  the  sestivo- 
autumnal  parasite  is  forty-eight  hours  ;  hence  a  "  malig- 
nant "  tertian  fever  is  not  uncommon. 

An  important  point  is  the  great  length  of  the  individual 
paroxysms  (when  such  can  be  Recognised),  often  up  to 
twenty-five  or  twenty-six  hours.  The  initial  chill  is  not 
so  common  as  in  the  other  forms,  but  the  general  constitu- 
tional symptoms  are  very  severe,  and  many  cases  show  a 
marked  similarity  to  enteric  fever  in  their  general  appearance. 
If  testivo-autumnal  malaria  is  neglected  very  grave 
symptoms  {so-called  pernicious)  are  hkely  to  develop. 
For  example,  the  patient  may  become  comatose  with 
shght  jaundice  and  small  punctate  haemorrhages,  or  menin- 
gitis may  be  sinmlated  (especially  in  children),  or  gastro- 
intestinal disturbance  may  be  so  profound  as  to  suggest 
cholera. 

Those  who  have  had  the  largest  experience  of  malaria 
agree  that  there  are  few  diseases  that  may  not  be  imitated 
by  tlH';  jMMiiicious  forms  of  the  iEstivo-autumnal  disease. 

The  Diagnosis  of  malaria  depends  upon  the  following 
points  :  — 

(i.)  The  history  of  previous  attacks  or  of  exposure  to 
infection.  Recrudescences  (especially  of  the  tertian  fever) 
may  occur  more  than  a  year  after  removal  from  a  malarious 
district. 

M.D.  9 


130  MEDICAL  DIAGNOSIS 

(ii.)  The  absence  of  leucocytosis  and  the  relative  increase 
in  large  mononuclear  cells. 

(iii.)  The  character  of  the  febrile  paroxysms  (in  tertian  or 
quartan  fever). 

(iv.)  The  most  important  diagnostic  point  is,  beyond  doubt 
the  discovery  of  the  parasite  or  its  products  in  the  blood.  In 
tertian  and  quartan  fevers  the  parasites  are  less  abundant 
in  the  peripheral  blood-stream  just  before  and  during  a 
paroxysm.  They  may  be  detected  in  a  fresh  preparation  or 
in  stained  films. 

{a)  To  make  a  fresh  preparation  prick  the  patient's 
finger  and  place  a  small  drop  of  blood  on  a  clean  slide  ; 
drop  a  thin  cover-slip  on  to  the  blood  and  allow  this  to 
spread  out  by  capillary  attraction  under  the  weight  of 
the  cover-slip  ;  finallj'  ring  the  cover  slip  Avith  vaseline. 
A  -12  inch  oil  immersion  lens  is  used  for  the  examination. 
The  parasites  appear  as  indistinct,  irregular  bodies  in 
the  centre  of  the  red  blood  corpuscles. 

Tertian  parasites  show  active  ammhoid  7novements ; 
quartan  parasites  are  more  sluggish.  Except  when  they 
are  very  young,  both  forms  show  pigment  granules  around 
their  periphery  or  collected  at  their  centres  in  the  later 
stages. 

In  tertian  cases  the  affected  blood-cells  are  large  and 

pale  ;  in  quartan  cases  they  tend  to  be  small  and  of  rather 

deeper  colour  than  those  which  do  not  contain  a  pa.rasite. 

The  quartan  parasite  is  more  highly  refractile  than  the 

tertian. 

If  the  blood  is  taken  shortly  before  a  paroxysm  is  due, 
segmentation  by  radial  lines  can  be  perceived  in  most  of 
the  parasites. 

(6)  To  Stain  Films  for  Malaria.  It  is  essential  to  spread 
a  very  thin  film,  which  may  be  stained  by  Giemsa's  or 
Leishman's  method  {vide  p.  155),  Jenner's  method,  carbol- 
thionin,  etc.,  as  preferred.  Giemsa's  and  Leishman's 
methods  stain  the  sporocyte  blue  with  red  spots  of 
chromatin  ;  fully  developed  spores  are  stained  blue  with  a 
red  centre.  In  cases  of  doubt  the  essential  things  to  look 
for  are  the  red  spots  of  chromatin  in  the  erythrocytes. 
In     aestivo  -  autumnal    fever    ring  -  shaped    bodies    in 


TROPICAL  DISEASES  131 

shrunken,  crenated  corpuscles  can  be  seen  in  the  blood  taken 
at  the  height  of  a  paroxysm.  Segmenting  bodies  are  rare  in 
the  peripheral  circulation,  but  can  be  seen  in  great  numbers 
if  splenic  puncture  is  performed. 

During  the  remissions  small  hyaline  pigmented  forms  may 
be  present  in  fair  numbers.  After  from  five  to  fourteen 
days  the  characteristic  crescent-shaped  bodies  with  centrally 
arranged  coarse  pigment  granules  can  usually  be  recognised 
with  ease. 

An  important  point  is  that  even  if  there  are  no  parasites 
to  be  discovered  in  the  blood  about  the  time  of  the  paroxysm, 
nevertheless  leucocytes  containing  masses  of  pigment  can 
generally  be  seen. 

Jaundice,  anaimia,  and  an  enlarged  spleen  are  all  points 
in  favour  of  sestivo-autumnal  malarial  infection. 

VII.  BLACKWATER  FEVER. 

This  disease  is  characterised  by  febrile  paroxysms  and  the 
passage  of  haemoglobin  in  the  urine. 

Blackwater  fever  only  occurs  in  patients  who  have  had 
malaria,  and  nearly  always  in  those  who  have  had  repeated 
attacks. 

Experimentally  c^uinine  may  induce  hsemoglobinuria  and 
clinically  cases  of  malaria  have  been  noted  in  which  ha^mo- 
globinuria  coincided  with  the  administration  of  quinine  ;  on 
the  other  hand,  there  is  no  doubt  that  blackwater  fever  may 
occasionally  occur  apart  from  the  taking  of  quinine.  Prob- 
ably the  combination  of  malaria  and  quinine  is  responsible 
for  the  very  great  majority  of  all  cases  of  blackwater  fever. 

Although  it  sometimes  happens  that  the  passage  of 
blackish  urine  is  the  first  manifestation  of  the  disease,  as  a 
general  rule  there  is  an  accompanying  febrik^  attack  not  unlike 
those  seen  in  malaria.  There  is  pain  in  the  loins,  spleen  and 
liver,  jaundice,  and  often  severe  bilious  vomiting. 

The  fever  lasts  a  variable  time,  and  as  it  subsides  the  urine 
resumes  its  natural  colour. 

Relapses  may  occur,  and  some  of  the  more  serious  cases 
])rogress  with  no  intermission  till  a  fatal  result  ensu(\s  from 
exhaustion  and  collapse. 

9—2 


132  MEDICAL  DIAGNOSIS 

VIII.  MALTA  FEVER  (Mediterranean  Fever). 

Malta  fever  is  a  specific  infective  disease,  endemic  to  the 
shores  of  the  Mediterranean  Sea,  and  characterised  by 
pyrexia,  perspirations,  constipation,  swelHng  of  the  joints, 
enlargement  of  the  spleen,  and  a  tendency  to  relapses. 

Bacteriology.  The  specific  micro-organism,  the  Micro- 
coccus melitensis,  was  discovered  by  Bruce  in  1887,  and  is 
a  small  coccus  often  arranged  in  pairs  and  tending  to  grow 
in  short  chains  when  cultivated  in  broth.  A  bacillary  form 
is  sometimes  met  with. 

The  micrococcus  stains  well  with  ordinary  dyes  and  is 
agglutinated  by  the  serum  of  Malta  fever  patients. 

The  organism  is  conveyed  to  man  in  the  milk  of 
infected  goats  in  the  very  great  majority  of  cases,  but 
indirect  contagion  by  fomites  is  certainly  theoretically 
possible. 

Incubation  Period.  The  incubation  period  is  about  fifteen 
days  (six  to  twenty  days). 

Course.  The  invasion  may  be  sudden  or  gradual.  The 
early  symptoms  are  those  of  general  constitutional  dis- 
turbance, especially  fever,  headache,  backache,  and  dys- 
pepsia. Vomiting  or  rigors  are  rare  at  the  outset,  but  nausea 
and  vomiting  may  occur  after  a  few  days.  The  general 
debility  increases,  the  spleen  becomes  tender  and  enlarged, 
the  tongue  is  coated  and  furred,  and  constipation  is  com- 
mon. Bronchitis  and  even  pneumonia  are  not  infrequent. 
These  symptoms  continue  for  from  one  to  three  weeks,  the 
temperature  remaining  elevated  all  the  time,  and  then  for 
a  few  days  there  is  very  great  amelioration,  and  the  patient 
appears  to  be  on  the  way  to  convalescence.  After  two  or 
three  days  of  well-being  the  symptoms  all  recur  again  ;  the 
spleen  becomes  especially  enlarged  and  anpemia  is  striking. 
In  this  stage  constipation  may  give  way  to  diarrhoea,  some- 
times with  blood-stained  motions.  Orchitis,  effusions  into 
various  joints,  or  even  endocarditis,  may  occur  in  the  more 
severe  cases.  Several  such  relapses  may  occur,  and  the  total 
duration  of  the  illness  varies  from  three  weeks  to  several 
months.  The  mortality  is  not  more  than  two  per  cent., 
but  during  the  illness  the  prostration,  apathy,  and  pallor 


TROPICAL  DISEASES  133 

indicate  the  severity  of  the  toxscmia.     There  is  no  leiieo- 
cytosis  in  Malta  fever. 

The  Diagnosis  depends  on  tlie  locality  in  which  the  case 
occurs,  the  type  of  fever,  with  relapses  and  splenic  enlarge- 
ment, the  absence  of  leucocytosis,  and  finally  on  the  agglu- 
tination power  of  the  patient's  blood  serum. 

IX.  PLAGUE. 

Plague  is  a  specific  infective  disease  produced  by  the 
Bacillus  pestis.  It  occurs  in  epidemics,  is  infectious  from 
case  to  case,  but  is  largely  conveyed  by  a  flea  which  ordinarily 
infests  rats,  but  which  may  s]iread  from  them  to  human 
beings.     In  many  eastern  cities  plague  is  now  endemic. 

Bacteriology.  The  plague  bacillus  as  seen  in  the  blood 
or  buboes  of  infected  persons  is  very  polymorphous ;  the 
most  usual  form  is  a  short  oval  rod,  but  long  rods  and  oval 
involution  forms  are  also  seen.  The  organism  grows  weil  on 
ordinary  culture  media ;  its  optimum  temperature  for  growth 
is  low,  being  only  30'  C.  It  stains  well  with  carbol-thionin 
or  dilute  fuchsin,  and  shows  marked  polar  staining.  It 
is  Gram -negative. 

Incubation  Period.  The  incubation  period  is  from  three 
to  ten  days. 

Varieties.     Clinically  four  forms  may  be  recognised  : — 
(i.)  Mild  Bubonic  Plague  (Pestis  kinor). 
(ii.)  Severe  Bubonic  Plague  (Pestis  Major), 
(iii.)  Pneumonic  Plague, 
(iv.)  Septicaemic  Plague. 

Clinical  Features,  (i.)  Pestis  Minor  is  never  fatal ;  it  may, 
however,  occur  in  epidemic  form  shortly  before  an  epidemic 
of  Pestis  major  and  is  characterised  by  mild  fever  and  the 
occurrence  of  glandular  swellings,  which,  however,  do  not 
often  suppurate. 

(ii.)  Pestis  Major,  (a)  PwflronalSfage.  Headache,  giddi- 
ness, staggering  gait,  mental  apathy,  and  often  bilious  vomit- 
ing, or  sometimes  ha^matemesis.  This  stage  lasts  up  to 
twenty -four  hours,  and  towards  the  end  the  temperature 
rises  steadily. 

(6)  The  Febrile  Stage.     A  severe  rigor  is  followed  by  a 


134 


MEDICAL  DIAGNOSIS 


temperature  of  103°  to  106°  F.,  which  reaches  its  maximum 
on  the  second  or  third  da3^  Prostration  is  extreme  ;  de- 
hrium  may  occur,  but  lethargy,  or  even  coma,  is  more  com- 
mon. A  loss  of  power  of  articulation  is  said  by  Dr.  Jennings 
to  be  very  constant  and  of  great  diagnostic  importance. 
After  about  five  days  the  temperature  falls,  often  almost  by 
crisis. 

The  characteristic  buboes  develop  on  the  second,  third, 
or  fourth  day  of  fever  and  occur  in  nearly  80  per  cent, 
of    oases.     The  inguinal  or  femoral  glands   are  the  most 

constantly  inv^olved,  and 
after  these  the  axillar5^ 
Internal  glands  are  found 
to  be  affected  in  fatal 
cases.  The  probable  cause 
of  the  glandular  enlarge- 
ment is  the  dissemination 
of  the  bacilli  throughout 
the  body  tissues. 

Suppuration  of  the 
buboes  is  a  late  sign  and 
ib  often  of  favourable 
significance.  Haemorrhages 
into  the  skin  and  from 
mucous  surfaces  are  not 
uncommon.  There  is  an 
extreme  leucocytosis,  often  up  to  90.000  or  even  higher. 

Very  severe  cases  may  end  fatally  within  twenty-four 
hours — that  is  to  say,  before  any  buboes  have  developed. 
The  total  mortality  varies  with  diiiferent  epidemics  and  at 
different  stages  of  the  same  epidemic,  but  all  in  all,  probably 
averages  fifty  to  sixty  per  cent. 

(iii.)  Pneumonic  Plague.  This  must  not  be  confounded 
with  secondary  broncho-pneumonia,  which  is  a  frequent 
complication  of  pcstis  major. 

The  first  sign  of  pneumonic  plague  is  usually  a  rigor  ; 
the  general  symptoms  of  pestis  major  then  occur,  but  in 
addition  there  is  cough,  blood-stained  sputum,  and  pleuritic 
pain.     There  is  no  primary  bubo  formation. 

Physical  examination  soon  shows  a  lobar  type  of  pneu- 


Fig.  31. — Bacillus  Pestis  from  Agar 
culture,  48  hours.  Magnification 
X  1000. 


TROPICAL  DISEASES  135 

monic  consolidation,  the  sputum  swarms  with  plague  bacilli, 
and  death  occurs  from  heart  failure  within  a  week.  This 
form  is  virulently  infectious  and  tends  to  reproduce  the  same 
variety  of  disease. 

(iv.)  Septic.5;mic  Plague.  This  can  hardly  be  dis- 
tinguished from  the  very  rapidly  fatal  form  of  pestis  major 
mentioned  above,  in  which  death  occurs  within  three  days 
and  in  which  no  buboes  have  time  to  develop.  There  are, 
however,  large  numbers  of  circulating  bacilli  in  the  blood- 
stream. 

The  diagnosis  of  plague  presents  little  difficulty  in  the 
presence  of  an  epidemic  or  if  the  characteristic  buboes  are 
present.  The  bacilli  can  easily  be  demonstrated  in  the 
material  removed  from  a  bubo  or  in  the  sputum  of  the 
pneumonic  form  ;  but  it  is  not  so  easy  to  find  them  in  the 
blood-stream,  except  in  the  septicsemic  type,  and  for  this 
purpose  it  is  advisable  to  perform  a  blood-culture  experiment 
as  described  on  p.  157.  ^ 

If  bacteriological  methods  are  not  available  and  there  are 
no  glandular  enlargements,  reliance  must  be  placed  on  the 
sudden  onset,  the  injected  conjunctiva,  the  coated  tongue 
with  a  red  margin,  and  the  extreme  prostration,  as  well 
as  the  peculiar  mental  condition  of  apathy  and  unwilling- 
ness or  inability  to  answer  questions. 

X.  SLEEPING   SICKNESS. 

Sleeping  sickness  is  an  endemic  disease  limited  to  certain 
parts  of  Africa  in  the  neighbourhood  of  the  Equator,  and 
characterised  by  increasing  mental  and  physical  lethargy, 
a  hectic  temperature,  and  a  fatal  issue. 

The  cause  of  slee})ing  sickness  is  a  protozoon  of  the  variety 
known  as  a  Trypanosome,  which  is  conveyed  to  human 
beings  and  also  to  animals  by  the  bite  of  the  tsetse  fly 
(Glossina  palpalis).  The  pathological  lesions,  according  to 
Mott,  are  chronic  meningo-encephalitis  and  meningo-myelitis. 

Clinical  Features.  The  onset  is  very  insidious,  and  the 
prodronal  stage  may  last  from  several  months  up  to  two 
years.  The  earliest  symptoms  are  a  change  in  mental 
attitude,  disinclination  to  do  things,   and  a  tendency  to 


136  MEDICAL  DIAGNOSIS 

drowsiness.  The  face  may  become  a  little  puffy  and  the 
expression  is  distinctly  apathetic.  The  gait  is  shuffling,  as 
if  it  was  too  much  effort  to  raise  the  feet,  and  a  tremor 
of  the  tongue  can  often  be  observed.  The  most  important 
diagnostic  point  at  this  stage  is  a  rise  of  temperature  each 
evening  up  to  101°  or  102°  F.  and  a  corresponding  increase 
in  the  pulse-rate  up  to  130  per  minute.  There  is  usually 
a  diffuse  glandular  enlargement. 

As  the  disease  progresses  drowsiness,  apathy,  and  muscular 
weakness  become  more  marked  ;  the  tremors  increase  and 
involve  the  hands  and  feet  ;  the  skin  becomes  dry  and 
coarse,  and  death  is  preceded  by  a  state  of  complete  coma. 

In  acute  cases  death  may  take  place  in  six  weeks  from  the 
case  coming  under  observation  ;  in  chronic  cases  the  duration 
is  much  longer,  and  temporary  remissions  are  common. 

The  diagnosis  depends  upon  the  presence  of  signs  as 
described  above  added  to  a  history  of  residence  in  an  area 
where  the  disease  is  endemic. 

The  Trypanosomes  can  be  demonstrated  in  the  cerebro- 
spinal fluid,  ill  the  blood,  and  especially  in  the  material 
removed  by  puncture  of  an  enlarged  gland.  For  this  pur- 
pose films  stained  by  Leishman's  stain  are  very  satisfactory. 

The  discovery  of  these  protozoa  serves  definitely  to 
exclude  cerebral  syphilis  or  general  paralysis,  unless  of 
course,  there  is  a  double  infection. 

XI.  SPRUE  (Psilosis). 

The  causation  of  sprue  is  unknown,  but  it  is  in  all  proba- 
bility a  specific  infective  disease. 

It  affects  principally  Europeans  who  reside  in  the  tropics, 
and  is  characterised  by  diarrhoea  with  the  passage  of 
numerous  pale,  frothy,  malodorous  stools  and  by  superficial 
ulceration  of  the  mucous  membrane  of  the  mouth  and  tongue, 
and  probably  of  portions  of  the  mucosa  along  the  entire 
alimentary  tract,  which  eventually  becomes  extensively 
atrophied. 

The  result  of  this  inflammation  and  atrophy  is  deficient 
assimilation,  so  that  there  is  progressive  starvation  and 
emaciation. 


TROPICAL  DISEASES  137 

Sprue  is  an  extrejiiely  clironic  disease  and  starts  very 
insidiously  ;  the  onl}^  symptoms  for  long  periods  may  be 
those  of  flatulent  dyspepsia  and  irregularity  of  the  bowels. 
A\'hen  the  disease  is  fuJlj^  developed  the  chief  symptoms 
are  : — 

(i.)  The  passage  of  copious  pale,  frothy,  drab-coloured 
offensive  motions. 

(ii.)  Tenderness  and  soreness  of  the  tongue,  cheeks  and 
fauces,  produced  by  loss  of  epithelium  and  the  formation 
of  vesicles  or  even  small  superficial  grey  ulcers. 

(iii.)  Flatulence. 

(iv.)  Wasting. 

(v.)  Anaemia. 

(vi.)  Cutaneous  pigmentation. 

Unless  efficient  treatment  is  employed  the  disease  is 
very  slowly  but  steadily  progressive,  with  various  brief 
remissions  and  relapses  till  death  takes  place. 

The  diagnosis  of  sprue  rests  upon  a  history  of  reside/jce 
in  the  tropics,  an  insidious  diarrhoeic  condition,  with 
lypical  stools  as  described  above  associated  A\'ith  a  sore, 
ulcerated  mouth,  ana-mia,  wasting,  and  pigmentation. 

XII.  YELLOW  FEVER. 

A  specific  infective  disease  characterised  by  fever,  jaundice, 
black  vomit,  suppression  of  urine,  and  derangement  of  the 
nervous  system . 

Yellow  fever  is  endemic  in  the  West  Indies,  part  of  the 
AVcst  Coast  of  Africa,  and  in  Brazil. 

The  specific  micro-organism  has  not  been  discovered,  but 
it  has  been  conclusively  proved  that  the  disease  is  conveyed 
to  man  by  the  bite  of  the  tiger  mosquito  (Stegomyia 
fasciata).  The  virus  is  only  present  in  the  blood  of  a  patient 
for  the  first  three  days  of  the  disease.  A  mosquito  fed  on 
yellow  fever  blood  cannot  communicate  the  disease  for 
twelve  to  fourteen  days.  The  infected  mosquito  may  live 
one  hundred  to  one  hundred  and  fifty  days,  and  may  com- 
municate the  disease  all  this  time  ;  it  is  also  ])robable  that 
the  offspring  of  an  infected  mosquito  may  also  be  infectious, 
though  how  far  this  goes  is  as  yet  uncertain. 


138  MEDICAL  DIAGNOSIS 

Incubation  Period.  The  incubation  period  of  yellow  fever 
is  usually  two  to  five  days. 

Course.  The  onset  is  sudden  :  the  first  symptom  is  a 
chill  or  rigor,  but  this  may  be  absent  ;  headache,  pains  in 
the  limbs,  pallor  of  the  skin  and  fever  next  appear.  The 
temperature  rapidly  rises  to  from  103°  to  106°  F.,  the  face 
becomes  red  and  swollen,  the  eyes  watery,  and  the  pains  in 
the  loins  and  limbs  increase. 

In  twenty-four  to  thirty-six  hours  the  maximum  of  the 
fever  and  constitutional  symptoms  is  reached  and  the  urine 
becomes  albuminous,  scanty,  or  even  suppressed.  On  the 
third  day  the  temperature  falls  and  the  symptoms  abate, 
and  some  cases  proceed  to  steady  convalescence.  About 
the  commencement  of  this  remission  yellowing  of  the  con- 
junctivae can  be  noticed. 

After  a  quiescent  interval  of  forty-eight  hours  in  many 
cases  the  gastric  symptoms  return  and  the  patient  becomes 
diffusely  jaundiced.  The  vomiting  is  persistent,  and  instead 
of  clear  or  bilious  fluid  the  vomited  material  becomes  black 
from  altered  blood.  Epistaxis  and  subcutaneous  haemor- 
rhages are  fairly  common. 

The  temperature  may  rise  again  or  may  remain  subnormal ; 
the  urine  once  more  becomes  diminished  or  suppressed  and 
loaded  with  albumin. 

If  the  patient  has  not  succumbed  from  toxaemia  and 
exhaustion  the  symptoms  gradually  disappear  from  the 
fifth  to  the  seventh  day  of  the  relapse.  The  mental  condition 
is  usually  dull  and  apathetic  ;  sometimes  the  mind  remains 
clear,  sometimes  there  is  delirium  ;  nearly  ahvays  the  patient 
fails  to  realise  how  ill  he  is. 

There  is  a  moderate  leucopenia  in  yellow  fever  (6,000  to 
3,000  white  cells  per  cubic  mm.)  and  a  slight  relative  increase 
in  the  large  lymphocytes. 

Diagnosis.  In  typical  cases,  in  an  endemic  area,  or  during 
an  epidemic  the  diagnosis  is  easy.  Malaria  can  be  diagnosed 
by  the  presence  of  the  parasite  in  the  blood,  though,  of 
course,  a  double  infection  may  exist. 

Blackwater  fever  is  proved  by  the  presence  of  hcemoglobin 
in  the  water  (hcematuria  may  sometimes  happen  in  yellow 
fever),    and  even  in  the  absence  of  the  spectroscope  the 


TROPICAL  DISEASES  139 

porter-colour  of  the  urine,  the  fact  that  it  settles  into  two 
layers,  the  uj^per  clear  and  port-wine  coloured,  and  the 
pink  tinge  imparted  to  the  froth  by  shaking  will  settle  the 
question  against  yellow  fever. 

Relapsing  fever  can  be  distinguished  by  the  enlarged 
spleen,  the  leucocytosis,  and  the  demonstration  of  the 
characteristic  spirillum  in  the  blood. 

For  the  differentia]  diagnosis  of  Weil's  disease  from  yellow 
fever  see  p.  384, 


CHAPTER  III 

CERTAIN   ANIMAL   PARASITES 

For  a  detailed  description  of  the  various  parasites  which 
may  occur  in  man  reference  should  be  made  to  text-books  of 
pathology.  Only  the  more  common  varieties  will  be  de- 
scribed here. 

I.  Cestoda  (Tapeworms).  The  following  tapeworms  are 
commonly  found  in  man  : — 

(i.)  Taenia  Saginata  (the  beef  worm). 

(ii.)  Taenia  Solium  (the  pork  worm). 

(iii.)  Bothriocephalus  Latus  (the  fish  worm). 

(iv.)  Taenia  Echinococcus  (in  cysticercus  form  only). 

(i.)  Tcenia  Sagiiiata.  The  intermediate  hosts  are  cattle, 
which  swallow  the  ova.  In  the  stomach  of  the  ox  the  envelope 
of  the  ovum  is  dissolved  and  the  embryos  burrow  through 
the  stomach  waU  and  become  encysted  in  the  muscles, 
with  the  formation  of  a  fibrous  capsule  (cysticercus  stage). 
The  cysticercus  is  about  1  cm.  in  diameter,  and  if  it  is  not 
destroyed  by  the  heat  of  cooking  and  is  swallowed  by  man 
the  head  becomes  attached  to  the  mucous  membrane  of  the 
intestines,  the  cyst  waU  is  lost,  and  a  tapeworm  develops 
with  the  following  characteristics  : — 

The  head  is  about  2  mm.  in  diameter,  and  is  furnished  with 
four  suckers  but  no  rostellum  or  booklets.  The  neck  is 
about  I  inch  in  length. 

The  fullj'-developed  worm  may  be  30  feet  long  and  have  as 
many  as  a  thousand  segments  or  proglottides,  which  increase 
in  size  as  the  distance  from  the  head  and  neck  increases 
until  the  full  width  of  about  |  inch  is  reached. 

Physiologically  active  proglottides  are  not  reached  till 
about  the  200th  segment,  they  are  bisexual  and  contain  a 
tubular  uterus  which  branches  dichotomously,  two  ovaries 
situated  near  the  posterior  part  of  the  segment,  and  testes 
which    are    visible    as    scattered  vesicles    throughout    the 


CERTAIN   ANIMAL   PARASITES  141 

segment.  The  uterus,  the  ovaries  and  the  testes  communicate 
with  the  exterior  by  a  genital  pore  which  is  situated  on  the 
border  of  each  segment.  The  proglottides  are  fully  mature 
about  the  COOth  segment  and  the  uterus  is  now  the  most 
conspicuous  feature,  the  other  sexual  apparatus  having  done 
its  work  and  faded  away.  About  eight  of  the  terminal  pro- 
glottides are  discharged  every  day  loaded  with  ova. 

(ii.)  Tcenia  Solium.  The  life  history  is  the  same  as  for 
Taenia  Saginata  ;   the  intermediate  host  is  the  pig. 

The  head  is  very  small  (about  the  size  of  a  pin's  head)  and 
the  neck  is  long  (about  one  inch).  The  segments  are  alto- 
gether smaller  than  in  Ta?nia  Saginata,  and  the  whole 
worm  is  rarely  more  than  10  feet  long. 

The  head  has  a  beak  or  rostellum.four  suckers,  and  twenty- 
six  chitinous  booklets,  which  are  arranged  in  two  rows. 

The  uterus  has  fewer  lateral  off-shoots  (10  to  12)  than 
Taenia  Saginata  (20  to  30),  and  does  not  branch  dichoto- 
mously. 

The  cysticercus  stage  may  occasionally  be  found  in  man, 
causing  small  cystic  swellings  in  the  brain,  muscles,  or  other 
tissues.  When  very  numerous  in  the  muscles  rheumatic 
pains  are  complained  of,  and  if  in  the  brain  the  signs  are 
those  of  cerebral  tumour. 

(iii.)  Bothriocephahis  Latus.  The  intermediate  host  is  a 
fish,  usually  the  pike.  The  worm  may  reach  25  feet  in 
length  and  have  3,000  to  4,000  segments. 

The  head  has  neither  suckers  nor  booklets,  but  is  furnished 
Avith  two  lateral  grooves. 

This  worm  is  sometimes  met  with  in  England  and  America, 
but  is  most  often  seen  in  Switzerland  and  Northern  Russia. 

The  presence  of  a  tapeworm  in  man  does  not  often  give 
rise  to  symptoms.  The  passage  of  proglottides  per  rectum 
is  usually  the  first  sign. 

Bothriocephahis  Latus  may,  however,  cause  a  grave 
ana;mia,  with  a  blood  picture  resembling  that  of  pernicious 
anaemia.  Insomnia,  loss  of  appetite,  and  vague  dyspeptic 
symptoms  are  sometimes  attributable  to  tapeworms,  and  in 
children  convulsions  and  meniugismus  may  occur,  but  are 
not  so  common  as  when  the  parasite  is  a  round  worm. 

In  treating  cases  of  tapeworm  the  head  must  be  carefully 


142 


MEDICAL  DIAGNOSIS 


sought,  as  unless  this  is  passed  the  worm  is  sure  to  grow 
again  in  a  few  months'  time. 

Taenia  Saginata  is  by  far  the  most  common  tapeworm  in 
Britain. 

(iv.)  Tcenia  Echinococcus.  The  cysticercus  stage  is  the 
only  one  that  is  found  in  man  ;  other  and  more  usual  inter- 
mediate hosts  are  sheep,  pigs,  and  cattle.  The  flesh  of  these 
animals  is  eaten  by  dogs,  wolves,  or  jackals,  and  the  worm 


Fig.  32.— Fluid  from  an  Hydatid.  Cyst,  showing — Hooklets, 
magnification  X  400;  Scolices,  magnification  X  260. 

develops  in  them.  The  eggs  are  passed  daily  and  lie  about 
on  the  grass,  where  they  are  taken  up  again  b}^  the  herbivora. 
Man  may  be  infected  by  eating  contaminated  greenstuff 
such  as  watercress,  or  directly  from  dogs,  as  these  may  carry 
the  ova  about  their  lips  and  mouths. 

The  worm  is  about  ^  inch  long  and  consists  of  a  head  and 
three  or  four  segments,  the  last  one  only  being  mature. 

The  head  is  provided  with  four  suckers,  a  rostellum,  and  a 
double  arch  of  from  30  to  50  booklets. 

When  an  ovum  is  received  into  the  human  stomach  it 


CERTAIN  ANIMAL  PARASITES  143 

loses  its  shell  and  the  small  six-hooked  embrj'o  burrows  its 
way  through  the  intestinal  mucous  membrane  ;  it  often 
reaches  the  blood-stream,  and  may  be  carried  to  any  part  of 
the  body.  The  liver  is  the  most  frequent  resting-place  ;  fifty 
per  cent,  of  hydatid  cysts  are  situated  in  this  organ. 

Wherever  the  embryo  is  deposited  it  loses  its  hooks  and 
becomes  converted  into  a  double-walled  cyst  (hydatid  cyst). 
The  outer  layer  of  the  cyst  is  composed  of  laminated  chitinous 
material  ;  the  inner  layer  is  granular  and  frequently  develops 
secondary  daughter  cysts,  which  project  into  its  cavity  like 
buds.  In  each  of  these  daughter  cysts  a  larval  head  (scolex) 
develops.  These  larva?  also  develop  directly  from  the  wall 
of  the  parent  cyst  without  the  formation  of  daughter  cysts, 
so  that  a  single  cyst  is  responsible  for  enormous  numbers  of 
scolices.  It  sometimes  happens  (especially  in  animals  other 
than  man)  that  the  daughter  cysts  project  externally  from 
the  mother  cyst  and  in  time  become  quite  separated  from 
the  parent  structure. 

The  fluid  contents  of  an  hydatid  cyst  consist  of  a  clear  non- 
albuminous  fluid  in  which  booklets  or  even  scolices  can  usually 
be  found. 

Symptoms  may  be  entirely  absent  ;  when  present  they 
are  the  same  as  those  of  any  other  tumour  in  the  particular 
organ  involved. 

Suppuration  in  an  hydatid  cyst  gives  symptoms  of  septic 
absorption. 

Rupture  of  an  hydatid  cyst  is  usually  fatal,  though  rupture 
into  a  lung  or  pleura  has  been  survived. 

The  diagnosis  of  Hydatid  Disease  is  helped  by  a  history  of 
close  association  with  dogs,  rc^iflence  in  Iceland  or  Australia, 
tJie  presence  of  eosinnphilia,  anrl.  in  the  case  of  the  liver,  a 
smooth,  painless  enlargement  wjiich  iiuitj  give  a  wavy  thrill  on 
percussion.  If  fluid  is  Avithdrawn  by  aspiration  the  presence 
of  booklets  is  pathognomonic. 

In  cases  of  doubt  the  patient's  })lood  serum  should 
be  tested  with  fluid  from  a  cyst  for  the  precipitin  reaction, 
which  is  ])ositive  in  a  considerable  proportion  of  cases. 

II.  Nematodes  (Round  Worms),  (i.)  Asraris  Lunihri- 
coidcs.  This  parasite  iniiabits  the  small  intestine  as  a  rukv 
l)ut  may  wander  into  the  stomach  and  be  vomited  or  into  tlu- 


144  MEDICAL  DIAGNOSIS 

large  intestine  and  be  voided  per  rectum.  It  may  occasion- 
ally reach  the  bronchus  {via  the  larynx),  or  even  the  accessory 
sinuses  of  the  nose  ;  it  may  invade  the  bile  ducts  and  cause 
jaundice. 

There  are  usually  two  worms  present  (male  and  female), 
but  sometimes  larger  numbers  are  found. 

Children  from  three  to  ten  years  are  mostly  affected. 

The  female  worm  is  about  10  inches  long  and  looks  very 
like  an  earthworm  ;  she  is  pointed  at  each  end  and  has  four 
longitudinal  lines  down  her  sides  ;  the  genital  pore  is  about 
the  middle  of  the  body. 

The  male  is  shorter,  being  about  five  or  six  inches 
long  ;  the  genital  pore  is  situated  near  the  hinder  end  and  is 
guarded  by  two  chitinous  spines. 

There  is  no  intermediate  host,  and  the  ova  are  conveyed 
in  contaminated  water  or  by  re -infection  from  scratching 
the  anus. 

There  may  be  no  symptoms,  but,  on  the  other  hand, 
very  curious  toxic  states  can  be  produced  by  these 
worms. 

General  malaise  and  vague  dyspeptic  signs  are  common. 

If  a  worm  is  in  the  stomach  repeated  vomiting  may  occur 
until  it  is  vomited  or  passed  out  through  the  pylorus. 
Anaemia,  meningismus,  convulsions,  giddiness,  and  irregular 
pyrexia  are  not  infrequent.  Vacancies  or  faints  in  young 
children  usually  mean  round  worms  or  epilepsy. 

It  is  obvious  that  none  of  these  symptoms  are  conclusive, 
but  their  occurrence  should  not  be  forgotten,  and  a  timely 
examination  of  the  fseces  for  the  ova  of  these  parasites  may 
clear  up  the  diagnosis  in  a  case  of  anomalous  symptoms 
in  a  sick  child.  Of  course,  the  passage  of  a  worm  by  a 
rectum  or  in  the  vomit  is  conclusive. 

The  ova  are  small,  brownish-red  oval  bodies  about  075 
mm.  in  length  ;  their  shell  is  thick  and  rough,  and  an  ill- 
defined  granular  embryo  can  be  seen  within. 

(ii.)  Oxyuris  V ermicularis  (Threadworm).  These  para- 
sites infest  the  whole  of  the  large  bowel.  They  resemble  to 
the  naked  eye  minute  threads  of  cotton.  The  female  is 
about  10  mm.  long  and  the  male  ratlier  less  than  half  that 
length. 


CERTAIN   ANIMAL   PARASITES  145 

During  the  night  the  worms  tend  to  migrate,  and  often 
emerge  at  the  anus  in  large  numbers. 

The  only  symptoms  are  anal  itching  and  general  irrita- 
bility. The  diagnosis  cannot  be  overlooked  if  a  cursory 
examination  is  nj^ade  of  the  faeces. 

(iii.)  Trichina  Spiralis.  The  development  of  trichiniasis 
depends  on  the  ingestion  of  raw  or  undercooked  pork, 
in  the  muscles  of  which  are  deposited  the  encj'sted  larvae  of 
the  Trichina  Spiralis.  The  parasite  is  killed  at  the  tempera- 
ture of  boiling  water  ;  hence  the  disease  is  most  prevalent  in 
Germany,  where  the  habit  of  eating  raw  or  imperfectly 
cooked  flesh  is  general. 

The  embrj^o  is  relieved  of  its  cyst  in  the  stomach  of  the 
new  host  and  passes  into  the  small  intestine,  where  it  reaches 
its  full  development  in  three  days.  The  adult  worms 
produce  large  numbers  of  embryos,  which  about  the  eighth 
or  ninth  day  have  penetrated  the  walls  of  the  intestine 
(unless  indeed  the  female  v/orm  herself  penetrates  the  intes- 
tine before  laying  her  eggs)  and  are  carried  by  the  blood- 
stream to  the  various  muscles  of  the  body. 

The  embryos  lodge  in  the  muscle  fibres  and  there  become 
encapsulated.  The  cyst  is  about  f  mm.  in  diameter  ;  the 
wall  is  translucent  at  first,  but  later  becomes  infiltrated 
with  lime  salts.  The  embryo  can  be  seen  coiled  up  in 
the  interior  of  the  cyst.  The  symptoms  coincide  with 
the  appearance  of  the  embryo  in  the  muscle  fibres  and 
are  : — 

(a)  Gastro -intestinal  disturbance  ; 

(6)  Fever  ; 

(c)  Muscular  pains,  stiffness  and  tenderness  ; 

{(l)  High    leucocytosis,    with    marked  eosinophiUa   (50 

per  cent.) ; 

(e)  G*]dcma   of   the   face,    with   perspirations,    tingling 

and  itching. 
In  most  cases  the  symptoms  gradually  abate  and  recovery 
takes  place  in  from  two  to  eight  weeks. 

The  diagnosis  depends  on  the  history  of  the  food  taken 
about  a  week  previously,  the  characteristic  muscle  symp- 
toms, the  (edema  of  the  face,  an<l  the  eosinophilia. 

The  adult  worms  can  often  be  seen  as  silvery  threads  in 

M.D.  10 


14G  MEDICAL   DIAGNOSIS 

the  fa3ces  if  these  are  examined  with  a  lens  against  a  dark 
background. 

Enteric  fever  is  exchided  by  the  leucocytosis  and,  later, 
by  the  negative  Widal  reaction  ;  rheumatism  by  the  absence 
of  joint  involvement  and  the  failure  to  react  to  salicylates. 

(iv.)  Ankylostoma  Duodenale  {Hoohivoi'tn).  This  parasite 
is  prevalent  in  southern  latitudes,  especially  Egypt,  but 
it  also  occurs  all  over  the  continent  of  Europe  and  in 
England  and  America  ;  it  has  repeatedly  caused  small 
epidemics  in  miners  (Miners' anaemia). 

The  worms  live  in  the  duodenum  and  jejunum  ;  the  female 
is  rather  more  than  |  inch  in  length  and  the  male  about 
I  inch.  They  have  a  mouth  which  is  supplied  with  teeth, 
by  which  they  fix  themselves  to  the  mucous  membrane. 
The  ova  are  discharged  in  the  faeces,  and  the  disease  is 
presumably  spread  by  contaminated  water. 

The  worms  suck  blood  from  their  host  and  so  cause 
the  anaemia  which  is  the  outstanding  symptom  of  their 
presence.  The  anaemia  is  of  the  chlorotic  type.  Associated 
symptoms  are  diarrhoea,  colic,  dyspnoea,  and  oedema. 

There  is  a  marked  leucocytosis  and  high  eosinophilia. 

For  diagnostic  purposes  an  anaemia  with  high  leucocytosis 
and  eosinophilia  should  lead  to  the  examination  of  the 
faeces,  when  hundreds  of  small  oval  eggs  ('6  mm.  by  '4  mm.) 
can  easily  be  recognised  with  a  lens  if  the  stools  are  com- 
pressed against  a  black  background. 

(v.)  Filar ia.  The  Filaria  Bancrofti  is  the  worm  the 
presence  of  which  in  the  lymphatics  is  a  frequent  cause  of 
elephantiasis  and  chyluria  in  certain  tropical  districts.  The 
female  is  some  3  inches  and  the  male  about  1|  inches  in 
length  ;  both  are  pale  in  colour  and  very  slender,  so  that 
they  resemble  white  horsehairs  in  appearance.  These 
adult  worms  may  live  for  years  in  the  lymphatics  of  man  ; 
the  female  is  viviparous  and  discharges  enormous  numbers  of 
very  slender,  highly  motile  filiform  embryos,  each  of  which 
is  loosely  surrounded  by  a  transparent  membranous  shell. 
Each  embryo  is  about  g^o  inch  in  length  and  the  same 
width  as  an  erythrocyte,  so  that  they  can  circulate  freely 
in  all  parts  of  the  blood-stream.  Clinically  they  are  found 
in  the  peripheral  circulation  only  at  night,  though  if  the 


CERTAIN   ANIMAL   PARA.SITES  147 

patient  sleeps  in  the  daytime  the  parasites  are  then  found 
only  in  the  daytime.  The  embrj^os  require  a  sojourn 
in  the  blood  of  a  mosquito  for  full  development,  and  are 
conveyed  back  to  man  when  the  insect  next  bites.  Those 
embryos  which  have  passed  through  a  moscpiito  phase 
are  the  only  ones  to  reach  maturity  in  man. 


Fig.  33.— Embryos  of  Filaiia  ]}ancrofti.     MaguiCicatioii  ;<  3G(). 

Filariasis  may  exist  without  causing  symptoms,  and  when 
symptoms  do  occur  it  is  by  tlie  more  or  less  accidental 
blocking  of  lymphatic  channels  by  the  new-laid  ova,  or 
possibly  by  the  adult  ones. 

It  has  ])eeif  suggested  that  elephantiasis  only  results  when 
the   feinale   worm   aborts,   foi-   tlie   immature  embryos   are 

10—2 


148  MEDICAL  DIAGNOSIS 

shorter,  thicker,  and  less  motile  than  the  fully -grown  embryo 
and  so  more  likely  to  block  the  lymphatic  channels. 

Clinically  filariasis  shows  itself  by  enormous  distension  of 
the  lymphatics  distal  to  the  blockage. 

The  most  common  clinical  manifestation  is  the  lymph-scro- 
tum, which  may  enlarge  so  much  as  to  weigh  many  pounds. 
The  tissues  are  in  a  state  of  brawny  oedema,  but  do  not 
readily  pit  on  pressure.  This  distinguishes  them  from 
ordinary  cardiac  or  renal  oedema.  The  legs  may  be  affected 
in  a  similar  manner. 

If  the  peri -renal  lymphatics  are  blocked  chyluria  results  ; 
the  urine  is  niillcy  in  appearance  and  contains  fat  droplets  ; 
blood  is  often  present  also. 

If  the  subperitoneal  lymph  plexuses,  are  blocked  chylous 
ascites  results. 

The  diagnosis  of  filariasis  depends  on  the  locality  in  which 
the  case  occurs,  the  characteristic  symptoms,  and,  above  all, 
the  presence  of  the  embryos  in  the  blood-stream  at  stated 
intervals.  In  fresh  preparations  a  low-power  magnification 
is  sufficient  to  show  the  embryos,  which  look  like  snakes 
wriggling  about  among  the  blood-cells.  The  embryos  stain 
well  with  dilute  fuchsin  or  eosin,  but  do  not  show  any  very 
definite  internal  structure. 

Various  other  forms  of  filaria  have  been  described  in  the 
blood  of  humans  and  animals,  but  it  is  doubtful  if  they  are 
pathological. 

Since  the  clinical  signs  (when  present)  are  purely  mechani- 
cal, similar  signs  may  be  found  if  the  lymphatics  are  blocked 
from  any  other  cause,  such  as  chronic  lymphangitis,  new 
growth,  etc.,  so  that  it  is  necessary  to  discover  the  embryo  in 
the  blood  before  making  a  positive  diagnosis  of  filariasis. 

(vi.)  Dracontiasis  {Filaria  31  edinensis  :  the  Guinea  Worm). 
This  parasite  is  prevalent  in  the  East  Indies  and  in  parts  of 
Africa.  Only  the  female  worm  is  known :  she  is  some  2  to 
3  feet  long  and  about  -^  inch  in  diameter. 

The  embryos  gain  access  to  the  human  stomach  in  drinking 
water  incorporated  with  a  "  cyclops,"  which  is  their  inter- 
mediate host.  The  male  embryos  die  ;  the  females  burrow 
through  the  stomach  wall  and  other  tissues  until  they  reach  a 
position  in  the  subcutaneous  tissues  of  the  leg.     Here  the 


CERTAIN  ANIMAL  PARASITES 


149 


female  completes  her  growth  and  eventually  discharges  her 
embryos  through  an  ulcer  on  the  surface  ;  she  can  be  felt 
underneath  the  skin  like  a  bunch  of  string. 

III.  Trematodes  (Flukes).  Sheep-rot  is  caused  by  the 
Distoma  Tiepaticum  ;  these  flukes  may  very  rarely  be  the 
cause  of  cholangitis  and  jaundice  in  man. 


t-:? 


o 


'gt*, 


r, 


(k, 


^ 


^ 


® 


Fig.  Hi.— Ova  and  Embrycs  of  Bilharzia  from  urinary  dt-posit. 
Magnification  x  210. 

Distoma  imhnonale,  a  parasite  about  'i  inch  long.  iiiha})its 
the  bronchial  tubes  and  is  the  cause  of  endemic  ha?mopt5'sis 
in  Coroa  and  Japan.  The  ova  can  be  recognised  in  the 
sputum. 

Disioma  hfBmatohiuDi  (Billiarzia)  is  the  most  important 
of  the  flukes  that  may  cause  symptoms  in  man. 


150  MEDICAL  DIAGNOSIS 

This  parasite  is  endemic  in  Egypt,  North  and  South  Africa, 
Persia,  and  parts  of  India. 

The  sexes  are  distinct  ;  the  male  (about  1  cm.  long)  is 
broader  and  flatter  than  the  female  (2  cm.  long)  and  is 
furnished  M'ith  a  groove  which  receives  the  female  during 
coitus.  The  eggs  are  oval  bodies  "16  mm.  by  "06  mm.  in  size, 
and  one  end  is  furnished  with  a  definite  spine.  Sometimes 
the  spine  is  lateral  instead  of  terminal,  and  it  is  said  that  those 
eggs  which  are  deposited  in  the  rectum  have  the  lateral  spine 
while  those  that  go  to  the  bladder  have  the  terminal  spine. 

The  mode  of  infection  is  uncertain,  but,  since  the  ova 
hatch  in  water,  contaminated  drinking  water  is  the  probable 
source.  The  adult  worms  live  in  the  portal  veins,  but  tend 
to  wander  towards  the  bladder  and  rectum,  in  the  tissues  of 
which  viscera  the  eggs  are  laid.  The  sharp -spined  eggs 
behave  like  other  foreign  bodies  and  tend  to  cause  irritation 
and  haemorrhage.  They  may  be  the  starting  point  of 
vesical  calculi,  and  may  cause  cystitis,  proctitis,  and  polypoid 
masses  in  either  rectum  or  bladder. 

No  symptoms  may  be  caused  ;  on  the  other  hand, 
frequency  of  micturition,  hsematuria,  and  cystitis  may  be 
found.  An  aching  pain  in  the  perinseum  is  not  uncommon. 
Tenesmus  with  the  passage  of  blood  and  mucus  may  lead  to 
the  discovery  of  the  ova  in  the  rectum.  The  loss  of  blood  is 
rarely  so  great  as  to  cause  more  than  a  slight  anaemia. 

Suspicion  of  this  disease  may  be  aroused  if  the  above 
symptoms  appear  in  one  who  has  visited  the  districts  above 
mentioned,  but  as  none  of  the  symptoms  are  pathognomonic, 
the  diagnosis  can  only  be  made  when  the  characteristic 
spined  ova  have  been  discovered  in  the  urine  or  in  the  faeces. 


'fw  boolcf 
-\b  lo  xlJIi 


i9bai£moi  sdT.  Jju^'lu  li-iuiuij  <:.  i'. 

i&aldole^em  rtdi  Jjn«  oi•^oo1di-{^»  edi  iv 

'  t  liorft  riti-w  Il'io  lA 


•  '   [■'::'   '  r,  oia'i  '<qoUjy>h   ti  l«rf)  tii 


)a)  TToziam-^aoQ.  odi  io 


.taal.lul 


.1190  ledSo  7,as  7o  9J70 
'rani  .1 


.9i-/ 

.laaliformoZ  bna 

ff'.')  in«»roiiri  ..  _     .1   .II 


Fig.  35 — This  picture  represents  all  the  blood  cells  (stained  by  Leishmans 
Btainj  which  may  be  met  with  in  health  or  disease,  and  also  a  primitive 
bone-marrow  cell  which  does  not  occur  in  the  peripheral  circulation  but 
which  h\-potheticaIly  maj-  be  the  ancestor  of  all  the  blood  cells,  except 
the  lymphocytes  which  are  manufactured  in  the  l5-mphatic  glands. 

The  large  mononuclear,  the  large  and  small  h-mphocj-tes,  and  all  the 
cells  in  the  bottom  row  are  met  with  in  normal  blood-  The  remainder 
are  only  found  in  disease. 

The  normoblast  is  the  parent  of  the  erythrocyte  and  the  megaloblast 
is  the  parent  of  the  normoblast. 

The  three  forms  of  granular  cell  with  their  respective  myelocyte  parents 
are  shown  on  the  right  of  the  diagram,  and  all  these  three  tj'pes  of 
myelocyte  are  descended  from  the  single  pre-myelocj't«  figured  above 
them. 

The  origin  of  the  large  mononuclear  cell  is  uncertain ;  it  is  probably  of 
endothelial  origin,  and  it  is  not  thought  that  it  develops  into  a  Ijinpho- 
cvte  or  any  other  cell. 

1.  Primitive  Hcemopoietic  Cell  of  the  Bone-marrow  (never  seen 

in  the  circulating  blood). 

2.  Pre-mye!ocyte  or  Myeloblast. 

3.  Xeutrophile  Myelocyte. 

4.  Basophile  Myelocyte. 

5.  Eosinophile  Myelocyte. 

H.  Pohinorphonuclear  Leucocyte. 

7.  Ma^t  Cells. 

8.  Eosinophile  Leucocj-te. 

9.  Megaloblast  and  Normoblast. 

10.  Erythrocj-tes  and  Blocd  Platelets. 

11.  Large  Mononuclear  Cell. 

12.  Large  Lymphocyte. 

13.  Small  Lymphocj-tes. 


^■i^^.K.'. 


.»•••:"■.••.■.-. 


'•*.■<!». 


■■v>:  ;;-*'' 


'^\*^^' 


• 


Ayiy:^.. 


^ 


e 


o 


(T* 


^J> 


• 


PART   II 

CHAPTER    I 
DISEASES  OF  THE  BLOOD  AND  BLOOD-FORMING  ORGANS 

I.  EXAMINATION  OF  THE  BLOOD. 

The  blood  consists  of  a  complex  solution  in  which  are 
suspended  various  cellular  bodies.  These  are  divided  into 
two  main  groups — red  and  white  cells. 

The  red  cells,  or  erythrocytes,  consist  of  un-nucleated, 
round  or  oval,  bi -concave  discs  about  7  fx  in  diameter.  They 
are  manufactured  in  the  red  marrow  of  the  bones  and  are 
present  to  the  number  of  5,000,000  in  every  cubic  millimetre 
of  blood.  In  women  there  are  rather  less,  usually  atout 
4,500,000  per  cubic  millimetre. 

The  white  cells,  or  leucocytes,  are  present  to  the  number 
of  7,800  in  every  cubic  millimetre,  and  comprise  various 
different  cells  in  healthy  blood.  The  morphological 
characters  described  b^low  are  those  which  become  evident 
when  Leishman's  or  .Tenner's  stains  are  used  {vide  Fig.  35) : — 
A.  Granular  cells  which  are  manufactured  in  the  bone 
marrow  : — 

(i.)  Polynwrphonudear  leucocytes.  These  cells  have 
a  multilobular  nucleus  (three  lobes  at  least  can  be  seen) 
which  stains  blue  and  has  colourless  surrounding  proto- 
plasm in  which  are  numerous  fine  neutrophile  (brick-red) 
granules  ((iO     75  per  cent.). 

(ii.)  Eosinophile  leucocytes,  Avliich  resemble  the  poly- 
morphomiclear  cells  except  that  the  nucleus  rarel}'  shows 
more  than  two  lobes  and  the  granules  are  larger,  more 
•rounded,  and  take  on  a  bright-red  colour  when  stained 
(1 — 3  per  cent.). 

(iii.)  Mast  cells,  which  have  a  deeply-staining,  irregular 
nucleus  and  very  coarse  basophile  (blue)  granules  (I  per 
cent.). 


152  MEDICAL  DIAGNOSIS 

B.  Non-Granular  cells  : — - 

(i.)  Small  or  ordinary  lymphocytes,  which  are  manu- 
factured in  the  germinal  centres  of  the  lymph  glands. 
They  are  rounded  cells  with  a  deep-blue  circular  nucleus 
which  almost  fills  the  cell,  leaving  only  a  very  small  margin 
of  paler  blue  protoplasm  (20 — 25  per  cent.). 

(ii.)  Large  lymphocytes,  which  closely  resemble  the 
small  lymphocytes,  except  that  they  are  definitely  larger 
in  size  (3 — 6  per  cent.). 

(iii.)  Large  mononuclear  cells  (hyaline  cells),  which  are 

possibly   of  endothelial  origin,   which  have  a  definitely 

phagocytic   action,   which  are  the  largest  cells  seen  in 

blood  films,  and  which  are  recognised  by  the  lighter  blue 

colour  of  their  irregular  (often  indented)  nucleus  and  the 

pale  blue  of  the  ample  surrounding  protoplasm  (2 — 4  per 

cent.). 

In  addition  to  red    and  white  cells  blood  2^^citelets  are  also 

found.     These  are  small  bodies  without  nuclei,  which  are 

seen  in  clumps  in  stained  blood  films  and  which  look  like 

debris.     They  are  present  to  the  number  of  about  250,000 

per  cubic   millimetre,   are  notably  diminished  in  purpura, 

and  are  probably  concerned  with  the  thrombotic  properties 

of  blood. 

The  red  colour  of  the  blood  is  due  to  the  haemoglobin  or 
oxygen  carrier  which  is  contained  in  the  red  cells.  The 
Colour  hidex  is  the  ratio  between  the  red  cells  and  their 


haemoglobin  content  I  i.e 


(amount  of  lisemoglobinA  „, 
number  of  red  cells  /' 
standard  of  100  per  cent,  represents  the  amount  of  haemo- 
globin present  in  the  blood-cells  of  a  healthy  man.  Since 
there  is  relatively  less  haemoglobin  in  the  blood  of  a  woman, 
the  normal  colour  index  for  women  is  only  '9,  whilst  for 
man  it  is  unity. 

For  a  complete  blood  examination  it  is  necessary  : — 
(i.)  To  enumerate  the  red  cells  and  the  white  cells, 
(ii.)  To  estimate  the  relative  proportions  of  the  various 
white  cells,    any   abnormality  in   the   red   cells,   and   to 
note  the  presence  of  any  cells  which  are  not  found  in 
health. 

(iii.)  To  estimate  the  colour  index. 


DISEASES    OF   THE   BLOOD  153 

(iv.)  In  some  cases  to  perform  a  blood  culture  experi- 
ment. 

(1)  To  enumerate  the  cells  a  Thoma-Zeiss  haemocytometer 
is  necessary.  This  instrument  consists  of  a  glass  slide  in 
the  centre  of  which  is  a  circular  platform  surrounded  by  a 
moat  and  depressed  below  the  level  of  the  rest  of  the  slide, 
so  that  when  covered  by  a  cover-slip  a  carefully  measured 
distance  (x^jmm.)  exists  between  the  top  of  the  platform 
and  the  bottom  of  the  cover-slip.  On  the  centre  of  the  plat- 
form are  ruled  400  small  squares  ;  they  are  arranged  in 
groups  of  sixteen  squares,  and  each  square  is  ^^y  of  a  square 
millimetre.  Therefore  the  space  between  each  square  and 
the  cover-slip  represents  exactly  ^oW  of  ^  cubic  millimetre. 
Two  graduated  pipettes  are  provided  for  collecting  the 
blood.  The  red  cell  pipette  provides  for  diluting  the  blood 
either  one  hundred  or  two  hundred  times.  The  white 
cell  pipette  for  dilutions  of  either  ten  or  twenty  times. 
Toisson's  solution  *  can  be  used  as  a  diluent  for  botl^  red 
and  white  cells.  If  preferred  Hayem's  solution  f  can  be  used 
for  the  red  cells  and  5  per  cent,  glacial  acetic  acid  tinged 
with  methyl  violet  for  the  white  cells. 

The  blood  is  obtained  by  pricking  the  lobe  of  the  ear  or 
the  finger  at  the  base  of  the  nail  with  a  needle  that  is  flat 
or  triangular  and  has  a  cutting  edge  as  well  as  a  sharp 
point.  The  part  should  be  cleaned  with  warm  water  and 
alcohol  before  puncture,  but  no  pressure  should  be  used  to 
make  the  blood  flow,  as  this  affects  the  number  of  white 
cells. 

The  red  cell  pipette  is  now  filled  to  the  mark  5,  wiped 
(piickly,  and  fiHed  to  the  mark  101  with  the  diluent.  A 
dilution  of  1  in  200  is  thus  secured.  If  Toisson's  solution 
is  used  for  the  white  cell  count,  the  red  cell  pipette  is  used 

*  Toisson's  solution  is  : — 

Methyl  violet,  -025  parts. 

Sod.  chloride,  1  ,, 

Sod.  sulphate,  H  „ 

Neutral  f,'lvcerine,      30  „ 

Distilled  water,         100  „ 

t  Hayem's  solution  is  : — 

Mercuric  chloride,  25  pirts. 

Sod.  chloride,  "5        ,, 

Sod.  sulphate,  23 

Distilled  water,  100 


154  MEDICAL  DIAGNOSIS 

for  collecting  the  blood — that  is  to  say,  the  same  dilution 
does  for  both  red  and  white  cells.  If,  however,  '5  per  cent, 
acetic  acid  is  used  for  the  white  cells,  the  larger  bore  pipette 
is  filled  in  precisely  the  same  manner  with  blood  up  to 
the  5  mark  and  with  diluent  ijp  to  the  11  mark,  thus  giving 
a  dilution  of  1  in  20.  The  pipette  must  be  shaken  gently 
to  mix  the  blood  well. 

A  few  drops  are  now  expelled  from  the  pipette  to  ensure 
reaching  the  mixture  in  the  bulb  and  a  small  drop  is  placed 
on  the  platform  and  covered  with  the  cover-slip.  This  drop 
must  not  be  so  big  as  to  overflow  into  the  moat.  It  is 
essential  that  both  counting  stage  and  cover-slip  are 
absolutely  clean,  dry,  and  free  from  dust.  If  the  proper 
care  has  been  observed,  concentric  prismatic  rings  of  light 
are  visible  on  the  cover-slip  (Newton's  rings).  A  No.  2 
eye-piece  and  a  ^  inch  objective  are  used  to  count  the 
cells. 

For  the  red  cells  the  number  is  counted  in  four  lots  of 
sixteen  small  squares.  This  number  divided  by  64  gives 
the  number  in  each  small  square.  If  the  number  in  each 
small  square  be  multiplied  by  4,000  the  number  of  cells 
in  a  cubic  millimetre  will  be  obtained  ;  but  the  blood  has 
been  diluted  200  times,  therefore  the  result  must  be  multi- 
plied by  200  to  get  the  number  of  cells  in  a  cubic  millimetre 
of  undiluted  blood. 

Thus,  if  X  be  the  number  of  cells  in  each  small  square, 
then  the  number  of  cells  in  a  cubic  millimetre  of  blood 
=  x  X    4,000  X  200. 

For  the  white  cells  it  is  best  to  count  in  fields  instead  of 
squares  ;  for  this  purpose  the  draw-tube  of  the  microscope 
is  drawn  out  until  the  diameter  of  the  field  is  exactly  eight 
small  squares.  Since  the  area  of  a  circle  is  ttt^,  the  area  of 
the  field  will  now  equal  almost  exactly  50  small  sqiuires. 
The  number  of  white  cells  in  100  consecutive  fields  should 
be  ascertained.  This  number  divided  by  100  and  again 
divided  by  50  gives  the  number  of  white  cells  in  each  small 
square.  If  the  number  so  obtained  be  multiplied  by  4,000 
and  also  by  the  dilution  of  the  blood,  the  result  will  be  the 
number  of  white  cells  in  a  cubic  millimetre  of  blood. 

Thus,  if  X  =  number  of  white  cells  in  100  fields,  then  the 


DISEASES    OF   THE   BLOOD  155 

number  of   white   cells  in   one    small    square  = 

50  X   100' 

and  the  number  of  white   cells   in    a   cubic  millimetre  of 

,  ,      ,       XX  4.000  X  dilution 

blood  = '■ . 

50  X  100 

The  calculation  is  simplified  if  Toisson's  solution  and 
a  dilution  of  1  in  100  be  used.  Under  these  circumstances 
the  number  of  white  cells  per  cubic  millimetre  of  blood  is 
obtained  by  multiplying  the  total  number  of  leucocytes  in 
80  fields  by  100. 

The  reason  why  it  is  necessary  to  use  larger  dilutions  with 
Toisson's  solution  as  a  diluent  is  that  with  small  dilutions 
so  many  red  cells  are  present  that  the  white  cells  are  con- 
cealed. If,  however,  the  acetic  acid  diluent  is  used,  the  red 
cells  are  destroyed,  so  that  it  is  possible  to  work  with  much 
smaller  dilutions. 

(?)  To  estimate  the  relative  number  of  the  different  white 
cells  present  it  is  necessary  to  examine  a  stained  blood  film. 

To  make  a  l)lood  film  a  small  drop  of  blood  is  placed  at  one 
end  of  a  glass  slide  ;  the  edge  of  a  7ia r rower  gl&^s  slide  is  used 
as  a  spreader  (preferably  the  spreading  edge  should  be  slightly 
convex).  The  film  is  spread  with  a  slightly  irregular  or 
jerky  movement.  When  spread  the  film  is  allowed  to  dry 
in  the  air. 

The  best  methods  of  staining  the  film  are  those  of  Jenner, 
Leishman,  or  Giemsa,  of  which  the  two  former  involve  the 
use  of  an  alcoholic  solution  of  methylene  blue  and  eosin  and 
are  used  for  fixing  the  film  as  well  as  staining  it. 

Jenner  s  Method.  Flood  the  dry  but  unfixed  film  with 
Jenner's  stain.  After  two  to  three  minutes  wash  off  the 
stain  with  a  brisk  stream  of  distilled  water  from  a  wash- 
bottle  ;  allow  the  fihn  to  dry  in  the  air,  and  mount  in  Canada 
balsam.  It  is  essential  that  the  stain  should  not  be  allowed 
to  dry  on  the  film. 

Leishinnns  Mclhod.  Pour  10  drops  of  Leishman's  stain 
on  to  the  dried  but  unfixed  film  and  leave  for  thirty  seconds  ; 
add  50  drops  of  distilled  water  and  leave  for  five  to  ten 
minutes.  Wash  in  distilled  water,  dry  with  filtre  ]iaper  and 
mount  in  Canada  balsam. 

Giemsa's  Method.     Cover  the  dried  but  unfixed  film  with 


156  MEDICAL  DIAGNOSIS 

absolute  alcohol  for  thirty  minutes.  Wash  off  the  alcohol 
with  distilled  water  and  dry  lightly  with  filtre  paper.  Pour 
on  to  the  film  2  c.c.  of  distilled  water  to  which  two  drops  of 
Giemsa's  stain  have  recently  been  added.  Leave  for  forty 
minutes  and  wash  off  in  a  brisk  stream  of  distilled  water. 
Dry  between  filtre  paper  and  mount  in  Canada  balsam. 

Each  of  these  methods  gives  admirable  results  : — 

The  red  cells  are  stained  pink,  nuclei  are  stained  blue,  the 
granules  of  the  polymorphonuclear  leucocytes  and  eosino- 
philes  are  stained  different  shades  of  red,  any  basophile 
granules  {e.g.,  those  of  mast  cells)  are  stained  blue,  and  the 
groundwork  of  the  lymphocytes  is  stained  pale  blue. 

In  making  a  differential  count  at  least  300  white  cells 
must  be  counted.  It  is  to  be  noted  that  they  tend  to  collect 
at  the  edge  of  the  film. 

Malarial  parasites  and  bacilli  are  stained  blue  by  these 
stains. 

(3)  To  estimate  the  amount  of  Haemoglobin.  Haldane's 
hsemoglobinometer  should  be  used.  This  consists  of  an 
empty  tube  with  a  scale  on  it  and  a  closed  tube  of  the  same 
size  containing  a  standard  solution  of  carboxy-haemoglobin 
corresponding  to  healthy  blood.  There  is  also  a  pipette 
with  a  mark  on  it  to  measure  20  cubic  millimetres. 

A  small  quantity  of  distilled  water  is  placed  in  the  empty 
tube,  the  pipette  is  filled  to  the  mark  with  blood,  and  the 
20  cubic  mm.  of  blood  so  obtained  are  blown  into  the  test- 
tube,  where  they  sink  to  the  bottom  of  the  distilled  water. 

A  stream  of  coal  gas  is  now  allowed  to  run  into  the  tube 
for  two  or  three  minutes  ;  it  is  not  allowed  to  bubble  through 
the  water.  When  the  tube  is  thoroughly  filled  with  gas  it 
is  closed  by  the  thumb  and  gently  inverted  to  permit  of  the 
conversion  of  the  oxyhsemoglobin  into  carboxyhaemoglobin. 
The  mixture  is  now  gradually  diluted  with  distilled  water 
until  its  colour  exactly  matches  that  of  the  standard  in  the 
control  tube.  After  each  addition  of  distilled  water  the 
contents  must  be  mixed  by  gentle  inversion  of  the  tube  and 
compared  with  the  standard. 

When  the  colours  are  identical  the  height  of  the  fluid  is 
read  on  the  scale,  which  is  graduated  to  show  percentages 
of  haemoglobin. 


DISEASES   OF   THE   BLOOD  157 

(4)  Blood  Culture  Experiment.  By  this  is  meant  the 
attempt  to  cultivate  any  micro-organisms  that  may  be 
circulating  in  the  blood.  It  is  advisable  to  withdraw  10  or 
15  c.c.  of  blood  from  a  vein,  and  it  is  essential  to  avoid  con- 
tamination with  skin  cocci.  When  no  vein  of  sufficient  size 
is  available,  the  ball  of  the  great  toe  may  be  thoroughly 
cleaned  with  soap  and  water,  alcohol  and  ether,  and  pricked 
with  a  needle  and  the  blood  collected  in  a  sterile  capillary 
pipette. 

If  a  vein  is  used  the  antecubital  fossa  on  one  side  should  be 
carefully  cleaned  with  soap  and  water  and  then  covered  with 
a  solution  of  iodine  in  rectified  spmt.  A  bandage  is  now 
apphed  to  the  upper  arm  so  as  to  distend  the  peripheral  veins. 
A  syringe  of  10  c.c.  capacity  containing  half  a  drachm  of  2  per 
cent,  citrate  of  sodium  solution  to  prevent  clotting,  and  fitted 
with  a  hollow  needle  1|  inches  long  and  of  medium  calibre,  is 
sterilised  in  an  autoclave  and  is  used  for  collecting  the  blood. 
In  order  to  ensure  that  the  syringe  and  needle  are  sterile  wl;en 
brought  to  the  bedside  it  is  convenient  to  have  a  screw 
adjustment  to  the  base  of  the  barrel  of  the  syringe  and  to 
screw  this  into  a  special  glass  cylinder  (like  a  large  test-tube) 
which  is  long  enough  to  take  the  syringe  with  its  needle 
already  attached. 

The  syringe  is  screwed  into  the  cylinder  ready  for  use  and 
then  the  whole  is  steriUsed  by  dry  heat.  The  apparatus  can 
now  travel  any  reasonable  distance  without  becoming  con- 
taminated, and  the  syringe  is  not  withdrawn  from  the 
cylinder  until  everything  is  ready  at  the  bedside. 

The  syringe  is  filled  with  blood  by  puncture  of  one  of  the 
distended  veins.  The  needle  is  now  removed,  the  nozzle  of 
the  syringe  passed  swiftly  through  the  flame  of  a  spirit  lamp, 
and  the  blood  straightway  expelled  into  a  flask  containing 
50  c.c.  of  sterile  bouillon.  Care  must  be  taken  in  expelling 
the  blood  that  it  goes  straight  into  the  culture  fluid  and  does 
not  trickle  down  the  neck  of  the  flask.  It  is  a  good  plan  to 
put  5  c.c.  of  blood  into  each  of  two  flasks  of  broth,  which  thus 
serve  as  controls  on  each  other. 

The  flask  containing  the  })lood  and  the  broth  is  iiiculiatod 
at  37  C.  for  seventy-two  hours.  Preparations  should  be 
made  every  twenty-four  hours  to  see  if  any  growth  has 


158  MEDICAL  DIAGNOSIS 

resulted.  If  there  is  any  growth,  subcultures  on  agar  agar, 
blood  agar,  gelatine,  and  other  media  must  be  made  in  order 
to  establish  the  identity  of  the  organism. 

Staphylococci  must  be  regarded  with  more  suspicion  than 
other  organisms,  since  the  blood  can  easily  be  contaminated 
from  the  skin. 

White  staphylococci  are  almost  certainly  contamination. 
Streptococci  or  pneumococci  are  important  as  indicating 
septici3emia.  Anthrax  bacilli,  gonococci,  and  Bacillus  coli 
may  be  demonstrated  in  appropriate  cases.  Bacillus 
typhosus  and  Bacillus  paratyphosus  can  nearly  always  be 
shown  about  the  third  day  in  cases  of  enteric  fever  or 
paratyphoid  infection.  It  sometimes  happens  that  the 
blood-serum  contains  so  much  anti-body  that  the  growth 
of  the  organisms  is  inhibited  unless  the  serum  is  enormously 
diluted  by  the  culture  medium.  This  is  most  likely  to 
happen  in  such  diseases  as  enteric  fever,  and  it  is  for  this 
reason  that  some  authorities  advise  the  inoculation  of  a 
series  of  ten  or  more  broth -tubes  with  different  amounts  of 
the  suspected  blood  from  one  drop  to  several  c.c.'s,  in  order 
to  arrive  at  that  dilution  which  is  most  favourable  to  the 
growth  of  the  particular  organism. 

II.  ABNORMALITIES  OF  THE  BLOOD. 

(a)  The  Red  Cells  and  Hsemoglobin.  These  are  both 
diminished  in  amount  in  cases  of  anaemia.  They  are  not  as 
a  rule  diminished  proportionately  ;  hence  there  may  be 
anaemia  with  a  low  colour  index  (chlorotic  type)  or  anaemia 
with  a  high  colour  index  (pernicious  type). 

Where  there  has  been  great  destruction  of  red  cells 
imperfectly  developed  red  cells  are  seen  in  the  blood.  These 
parent  cells  are  called  normoblasts,  and  resemble  the  ordinary 
red  cell  except  that  they  are  nucleated.  In  severe  cases  the 
parent  cell  of  the  normoblast,  namely  the  megaloblast,  may 
appear.  This  is  a  large  cell  with  an  irregular  nucleus  which 
stains  variably  and  is  often  split  up  into  two  or  three  parts. 
The  megaloblast  is  only  found  in  pernicious  anaemia,  in 
certain  parasitic  infections,  in  nitrobenzol  poisoning,  and 
possibly  in  the  last  stages  of  cancerous  cachexia.  Its 
presence  is  of  grave  significance. 


DISEASES   OF   THE   BLOOD  159 

Great  variability  in  shape  and  size  of  the  red  cells  (poikilo- 
cytosis)  and  in  the  way  they  take  the  stain  (polychronia- 
tophilia)  is  a  feature  of  pernicious  forms  of  anaemia.  In 
polychromatophilia  some  of  the  red  cells  are  orange,  some 
are  grey,  and  some  are  stippled  with  little  blue  points. 

But  little  importance  can  be  attached  to  variations  in 
the  colour  index  or  in  the  number,  shape,  size,  and  varieties 
of  red  cells  found  in  infancy. 

There  may  be  an  increase  in  the  total  number  of  red 
cells  (polycythsemia)  in  the  following  conditions  : — (i.)  Preg- 
nancy ;  (ii.)  High  altitudes  ;  (iii.)  Carbon-monoxide  poison- 
ing ;  (iv.)  With  certain  forms  of  splenomegaly  ;  (v.)  Con- 
genital heart-disease  ;  (vi.)  New-born  infants  ;  (vii.)  Severe 
cholera. 

It  is  sometimes  desirable  to  estimate  the  fragility  of  the 
red  cells,  for  example,  in  acholuric  jaundice,  but  the  results 
are  not  altogether  reliable. 

To  perform  the  experiment  suspensions  of  the  patient's 
red  cells  arc  made  in  saline  solution  of  different  strengths 
from  •!  per  cent,  to  1  per  cent.,  and  the  strongest  salt  solu- 
tion noted  in  which  haemolysis  occurs.  Healthy  blood  cells 
do  not  liffimolyse  in  stronger  saline  than  '45  per  cent. 

A  set  of  control  tubes  should  always  be  put  up  containing 
known  healthy  red  c.dls. 

(b)  The  White  Cells.  An  increase  in  the  number  of  the 
white  cells  is  known  as  a  leucocytosis.  A  physiological 
leucocytosis  up  to  about  10,000  or  1 1,000  is  commonly  found 
shortly  after  a  large  meal,  and  during  the  latter  months  of 
pregnancy.  In  infancy  the  white  cell  count  is  often  between 
20,000  and  30,000. 

Pathological  leucocytosis  occurs  in  all  forms  of  inflamma- 
tion except  a  localised  abscess  which  is  draining  freely. 

It  is  also  seen  in  nearly  all  the  specific  infective  diseases 
except : — 

Enteric  Fever, 

Tuberculosis  (except  Tuberculous  Meningitis). 

Measles  and  German  Measles. 

Malta  Fever. 

Mum])s. 

Chicken-pox. 


160  MEDICAL  DIAGNOSIS 

Influenza. 
Yellow  Fever, 
Malaria. 
Kala  Azar. 
Syphilis. 

In  the  varieties  of  leiicocytosis  hitherto  considered  the 
increase  is  principally  in  the  polymorphonuclear  leucocytes. 
It  is  important  to  remember  that  in  all  varieties  of  tuber- 
culosis there  is  likely  to  be  a  relative  increase  in  the  number 
of  lymphocytes. 

Extreme  leucocytosis  (above  100,000)  is  only  met  with 
in  cases  of  leukaemia,  either  Spleno -medullary  or  Lymphatic, 
or  very  occasionally  in  whooping-cough  or  plague. 

In  spleno -medullary  leukaemia  the  increase  is  mostly  in 
polymorphonuclear  leucocytes  and  their  parent  cells,  the 
myelocytes  ;  the  lymphocytes  are  also  increased  absolutely, 
though  diminished  relatively.  The  myelocyte  is  a  large 
cell  with  a  faintly-staining,  often  indented  nucleus,  and 
numbers  of  granules  which  may  be  neutrophile,  eosinophile, 
or  basophile.     It  is  not  present  in  health. 

In  lymphatic  leukaemia  the  increase  is  entirely  in  the 
lymphocytes. 

Leucopenia,  or  diminution  in  the  number  of  white  cells 
below  6,000,  is  most  often  seen  in  pernicious  anaemia, 
enteric  fever,  splenic  anaemia,  influenza,  malaria,  yellow 
fever,  and  kala  azar. 

III.  ANEMIA. 

The  classification  of  the  anaemias  into  primary  and 
secondary  is  not  satisfactory.  It  is  probable  that  all 
anaemias  (except  anaemia  from  haemorrhage)  are  secondary 
to  the  action  of  toxins  (bacterial  or  chemical)  manu- 
factured elsewhere  than  in  the  blood-stream  or  blood- 
forming  organs,  and  therefore  that  anaemias  are  all  secondary, 
even  though  in  many  cases  no  primary  cause  can  be  estab- 
lished either  clinically  or  post  mortem. 

(a)  Anemia  AFTER  HEMORRHAGE.  The  total  quantity  of 
fluid  is  made  up  in  a  few  hours.  The  number  of  red  cells 
returns  to  the  normal  in  about  three  weeks,  but  the  deficiency 
in  haemoglobin  is  not  made  good  for  two  or  three  months 


DISEASES   OF   THE   BLOOD  161 

after  a  severe  haemorrhage.  The  appearance  of  poikilo- 
cytes  and  normoblasts  is  common  durmg  the  stages  of 
repair,  and  a  distinct  leucocytosis  is  the  rule  during  the 
early  stages. 

(6)  Chlorosis.  This  is  a  common  disease  of  girls  and 
young  women.  It  starts  at  or  shortly  after  puberty,  and  is 
generally  cured  by  marriage  and  childbirth. 

The  pathology  is  obscure,  but  it  seems  probable  that  the 
ovarian  internal  secretion  and  auto-intoxication  from  con- 
stipation may  each  play  a  part.  The  predisposing  causes 
are  defective  hygiene  and  lack  of  sunshine,  exercise,  and 
good  food. 

Symptoms  and  signs.  The  girl  is  often  well  nourished 
but  flabby.  She  may  have  a  red  flush  on  the  cheeks,  some- 
times (if  a  brunette)  she  is  a  definite  greenish-yellow  colour. 
In  all  cases  the  mucous  membranes  are  pale. 

The  cardinal  symptoms  are  dyspnoea  on  exertion,  palpi- 
tations, indigestion,  constipation,  disordered  menstrua^tion 
(usually  scanty,  sometimes  increased),  a  tendency  to  faint- 
ncss  and  swelling  of  the  feet  in  the  evenings. 

A  haemic  murmur  is  frequently  heard  over  the  pulmonary 
area,  and  in  some  cases  the  myocardial  debility  is  so  great 
as  to  permit  of  dilatation  of  the  mitral  ring. 

The  bruit  de  (liable,  a  continuous  buzzing  sound  in  the 
jugular  veins,  is  described  in  connection  with  chlorosis. 
This  is  of  little  diagnostic  value,  as  it  so  largely  depends  on 
the  pressure  of  the  stethoscope. 

The  Blood.  The  total  quantity  of  the  blood  serum  is 
increased.  The  haemoglobin  is  markedly  diminished,  often 
down  to  30  or  40  per  cent.  The  red  cells  are  moderately 
diminished,  usually  70  to  80  per  cent.,  but  in  view  of  the 
hydra;mic  plethora  the  diminution  in  the  total  number  of 
red  cells  is  but  slight.  The  colour  index  is  low,  usually 
about  •().  The  white  cells  are  unaltered,  but  there  may 
be  a  slight  relative  lymphocytosis.  In  very  severe  cases  a 
few  normoblasts  may  be  seen. 

Complications.  Gastric  ulcer,  headaches,  neuralgia,  venous 
thrombosis  (sometimes  of  the  (U'rebral  sinuses),  and  occa- 
sionally o])tic  neuritis  are  the  most  important  complications. 

The  diagnosis  of  clilorosis  depends  on  Ihc  Itlood  picture, 

M.D.  11 


162  MEDICAL   DIAGNOSIS 

the  age  and  sex  of  the  patient,  the  signs  and  symptoms 
above  described,  and  the  absence  of  any  discoverable  cause 
for  the  anaemia.  Every  case  should  be  carefully  examined 
with  a  view  to  the  possibility  of  early  pulmonary  tubercu- 
losis. 

(c)  Pernicious  Anemia  (Idiopathic  Anaemia  of  Addison). 
The  pathology  of  this  disease  is  very  obscure,  but  it  is 
probable  that  the  error  lies  in  excessive  destruction  of  red 
cells  through  some  toxic  agency  rather  than  in  the  diminished 
activity  of  the  haemopoietic  centres.  The  origin  of  the 
toxins  is  thought  by  some  to  lie  in  oral  or  gastro -intestinal 
sepsis,  but  the  evidence  is  not  conclusive.  The  destruction 
of  the  red  cells  is  accompanied  by  the  deposit  of  haemo- 
siderin  in  the  liver  and  kidneys,  and  sometimes  in  the 
spleen. 

Pernicious  anaemia  affects  men  rather  more  frequently 
than  women  ;  it  usually  starts  between  the  ages  of  30  and 
50  and  develops  very  insidiously.  It  is  unusual  for  the 
patient  to  seek  advice  until  the  disease  is  well  advanced. 

Symptoms  and  Signs.  The  symptoms  are  lassitude, 
muscular  weakness  and  shortness  of  breath  ;  often  there 
is  abdominal  pain,  and  vomiting  is  not  infrequent. 

Examination  of  the  patient  will  show  a  peculiar  lemon 
yellow  coloration  of  the  skin  ;  the  subcutaneous  tissues  are 
well  preserved.  In  severe  cases  there  will  be  evidence  of 
fatty  degeneration  in  the  heart  muscle  {vide  p.  237).  The 
activity  of  the  haemopoietic  tissues  may  be  shown  by  tender- 
ness in  the  shafts  of  the  long  bones  and  in  the  sternum. 
There  is  usually  a  moderate  enlargement  of  the  spleen. 
Haemorrhages  are  frequent  in  the  later  stages,  both  from  the 
mucous  membranes  and  into  the  retinae.  An  extremely 
important  phenomenon  is  the  occurrence  of  sclerosis  in  the 
posterior  and  lateral  columns  of  the  spinal  cord,  which  may, 
in  some  cases,  give  rise  to  ataxy  and  paresis.  This  degenera- 
tion is  identical  with  that  found  in  "  Subacute  Combined 
Degeneration  of  the  Cord  "  {vide  p.  556),  and  it  is  possible 
that  the  two  diseases  are  produced  by  a  common  cause. 

The  temperature  shows  periodic  waves  of  moderate 
fever,  each  wave  lasting  for  two  or  three  weeks  and  alter- 
nating with  an  apyrexial  period  of  varying  length. 


Fig.  3G. 


Fig.  :?7. 


I'lG    36. — This  picture  represents  a  blood  film  from  a  case  of   Pernicious 
Anoimia,  stained  by  Leishman's  stain. 

A  typical  blood  count  in  such  a  case  is  as  follows : 

Red  Cells     .     .     1.500,000,  including  normoblasts  and  megaloblasts. 
Haemoglobin     .     4-5  per  cent. 
Col oiir  Index    .     1*4 . 
White  CeUs .     .     4..500. 

Polj'morphonuclcar  Cells     .     55  per  cent. 
Small  Lymphocytes   ...     30       ,, 
Large  Lymph ocj-tes  .     .     .     15 


Fig.  37. — This  picture  represents  a  bleed  film  from  a  case  of  Myelogenous 
or  Spleno-medullary  Leukrcmia   stained  by  Leishman's  stain.  ^ 

A  typical  blood  count  in  such  a  case  is  as  follows : 
Red  Cells      .     .     2,.500,000. 
Haemoglobin      .     30  per  cent. 
Colour  Index     .     "66. 
White  Cells  .     .     500,000. 

Polymorphonuclear  Leucocj-tes 35  per  cent. 

Eosinophile  Leucocytes   . "5 

Mast  Celb* 5 

Myeloc\-tes 40 

Large  Mononuclear  (possibh*  Pre -myelocytes)       5 
L>Tnphocytes 10 


<  ■•^'^■^  '■  ,i,uou  boold  Ifioiq-tT*  A 

.k- 1     .    y.oj^nl  luoIoO 
'".Oo.tidYA 


/I                         _         ,  uiaie   mswsotXuoJL  \4t»^Wb3m-OM9\c[?»  to 
BwoUoJ  8«  8J  88«o  «  doo8  01  jauoo  fcoold  laoiq^*  A 
'i'iO.OOfl.2     .     .      elbOfcoa 
foq  08     .      nidoI^oraasH 
'■*•     .     xebnl  ijjoIoO 
.     .  elbO  9iiif7^ 
30  Tsq  ■ ''  r-iylo^ 


)iii-..7m-oiM  7Hfi'->."'rj   T)i')i'jm:i> 
^^  .      m\. 


DISEASES   OF   THE   BLOOD  163 

In  the  majority  of  cases  there  are  one,  two,  or  more 
remissions  in  which  there  is  an  amelioration  of  all  symptoms 
and  a  great  improvement  in  the  anaemia.  Such  remissions 
may  last  for  six  months  or  longer,  but  they  are  never  per- 
manent. 

The  urine  contains  an  excess  of  urobilin,  but  no  bilirubin  ; 
there  is  often  albuminuria. 

The  Blood  (v^(7e  Fig.  36)  shows  very  characteristic  changes: — 
The  red  cells  are  reduced  to  between  20  and  40  per  cent.,  or 
even  lower.  There  is  poikilocytosis  and  polychromatophiha. 
Normoblasts  and  megaloblasts  are  present.  The  haemo- 
globin is  reduced  to  from  50  to  60  per  cent.  ;  consequently 
there  is  a  high  colour  index.  The  white  cells  are  diminished 
in  amount,  often  below  5,000,  but  there  is  frequently  a 
slight  relative  lymphocytosis. 

Diagnosis.  The  blood  picture  is  characteristic,  and  in 
conjunction  with  the  symptoms  and  physical  signs  makes 
the  diagnosis  easy.  ^ 

In  very  early  cases  there  may  be  a  low  colour  index,  and 
the  same  thing  may  occur  during  one  of  the  remissions. 

The  important  features  of  the  blood  picture  are  megalo- 
blasts, high  colour  index,  and  leucopenia. 

A  megaloblastic  type  of  blood  is  sometimes  seen  in  cases 
of  intestinal  parasites  (ankylostoma  duodenale,  bothrio- 
cephalus  latus,  etc.),  but  there  is  no  leukopenia  in  these 
conditions,  and  there  is  usually  a  marked  increase  in  the 
number  of  eosinophilc  cells. 

Cancer  of  the  stomach  may  produce  a  somewhat  similar 
red  cell  picture,  but  is  usually  accompanied  by  leucocytosis, 
while  investigation  of  the  gastric  contents  {vide  p.  327)  and 
examination  of  the  abdomen  should  prevent  error. 

Nitrobenzol  poisoning  gives  a  similar  picture  except  for 
the  leucopenia  but  can  be  diagnosed  from  the  history. 

Chronic  plumbism  causes  a  somewhat  similar  anaemia, 
but  the  colour  index  is  rarely  above  unity,  and  there  is  more 
basophilic  degeneration  of  the  red  cells.  Megaloblasts 
are  usually  absent,  while  the  history  and  physical  signs, 
such  as  blue  line,  wrist  drop,  colic,  constipation,  headache, 
and  high  blood  pressure,  should  be  conclusive. 

The    aplastic    type    of    pernicious    anaemia    occurs    more 

11—2 


164  MEDICAL   DIAGNOSIS 

often  ill  women  than  men,  and  favours  the  young  adult 
rather  than  the  middle-aged. 

It  suggests  a  failure  on  the  part  of  the  hasmopoietic 
bone  marrow  to  respond  to  the  call  made  on  it  for  the 
formation  of  new  red  cells  by  the  action  of  toxins  allied 
to  those  of  pernicious  ansemia. 

The  result  is  a  great  diminution  in  red  cells,  with  a 
colour  index  of  about  unity  and  no  nucleated  forms, 
poikilocytosis  or  polychromatophilia. 

Treatment  has  no  effect  and  the  disease  runs  a  rapidly 
fatal  course. 

IV.    LEUKAEMIA. 

Two  main  forms  of  leukaemia  are  recognised  : — the  Spleno- 
medullary  and  the  Lymphatic.  In  some  few  cases  these 
varieties  may  both  be  present  in  the  same  person,  giving 
rise  to  a  mixed  leukaemia.  In  both  forms  the  symptoms 
are  much  the  same^an  insidious  onset,  with  weakness, 
dyspnoea,  lassitude,  emaciation,  gas tro -intestinal  disturb- 
ance, and  often  haemorrhages  from  the  mucous  surfaces, 
especially  menorrhagia  and  epistaxis.  The  temperature, 
as  in  pernicious  anaemia,  shows  waves  of  elevation  alternating 
with  apyrexial  periods. 

(a)  Spleno -MEDULLARY  (Myelogenous)  Leukemia.  The 
spleen  is  enormously  enlarged,  often  extending  to  the  pelvis. 
Occasionally  there  is  tenderness  over  the  sternum  and  long 
bones.     The  liver  is  often  considerably  enlarged. 

The  Blood  (Fig.  37)  shows  very  characteristic  changes. 
There  is  a  red-cell  anaemia  of  chlorotic  type.  There  is  a 
leucocytosis  up  to  500,000,  due  to  an  increase  in  poly- 
morphonuclear cells  and  their  parent  cells,  the  myelocytes. 
These  two  cells  are  often  present  in  about  equal  numbers, 
together  forming  from  80  to  90  per  cent,  of  the  total  white 
cells.  In  some  cases  the  increase  is  almost  entirely  myelo- 
cytic. At  the  same  time  there  is  an  increase  in  the  eosino- 
phile  cells  and  in  mast  cells.  The  lymphocytes  are  absolutely 
increased,  though  relatively  normal  or  diminished. 

The  diagnostic  features  are  the  abundance  of  myelocytes, 
which  are  not  present  at  all  in  health  (they  may  be  neutro- 


Fw.  38. 


Fig.  39 


Fig.  38. — This  picture  represents  a  blood   film    from    a   case   of   Chronic 
Lymphatic  LeulccBmia  stained  by  Leishmans  stain. 
A  typical  blood  count  in  such  a  case  is  as  follows  : 
Red  Cells       .     .     2.000.000. 
Hamoglobin      .     20  per  cent. 
Colour  Index      .     'o. 
White  Cells   .     .     150.000. 

Polymorphonuclear  Cells     .       5  per  cent. 
Small  Lj'mphocytes    .     .     .     90      ,  „ 
Large  LjTnphocj'tes         .     .       o""    „^ 


Fig.   39. — This   picture   represents   a   blood   film   from   a    case   of    Ac^de 
Lymphatic  Lenkcemia,  stained  by  Leishmans  stain. 
A  tj'pical  blood  count  in  such  a  case  is  as  folloM's: 
Red  Cells      .     .     800.000. 
Hfemoglobin      .     10  per  cent. 
Colour  Index     .     "6. 
White  Cells        .     50,000. 

Large  L3'mphoc3'tes    ...     85  per  cent. 
Small  Lymphocj-tes    ...     10         ,, 
Polymorphonuclear  Cells      .       5         ,, 


on<otAO   io   iee^tM    moit    mlR    Iroold  e  einoeg-tqai  aiuioiqv^  BidT — .88    oi^ 

!'.:     ,„    nidoF3o«i3iiH 
'  >hnl  itfoIoO 


ifitfi>udamydr  aai*  J 


fiqm\dr  t 


aiwak    lo  eaea    «    moil   mlh    boo\<i   e   8in9*!9iq9i   atuioiq   erriT— .G8   .oil 

~   ^^      — (T-^  ;oJ  vd  bsflifiia  .omg^iwsi  m^oAc51«\sA 

^?.ao.B  dons  ai  iauoo  boold  [fioiq"^vt  A 

^000^08     .     .      alfoObaa 

n  leq  01.     .      nidoIgomeeH 

.9"  v.     xsbal  TuoIoO 

.OOO.OS   \      BlIaOo^idYA 

:  IlAjcna 


DISEASES    OF   THE   BLOOD  165 

phile,  eosinophile,  or  basophile,  but  these  latter  are  relatively 
scanty),  and  the  increase  in  mast  cells. 

(6)  Lymphatic  Leukemia  (Chronic  form).  The  lymphatic 
glands  throughout  the  body  are  enlarged,  the  individual 
tumours  usually  remaining  discrete  and  freely  movable. 
As  a  result  of  enlargement  of  the  thoracic  glands  pressure 
effects  are  not  uncommon. 

The  spleen  is  considerably  enlarged,  but  not  as  a  rule  to 
the  same  extent  as  in  the  spleno-medullary  form.  The  liver 
is  moderately  enlarged. 

The  Blood  (Fig.  38)  is  very  characteristic.  There  is  a  red 
cell  anaemia  with  a  low  colour  index.  There  is  a  white  cell 
count  of  from  loO,000  to  200,000  and  of  these  cells  95 
per  cent,  are  small  lymphocytes.  No  myelocytes  are 
present. 

(c)  Lymphatic  Leukemia  (Acute  form).  This  disease 
occurs  chiefly  in  childhood  and  adolescence  ;  it  is  associated 
with  a  septic  (often  gangrenous)  inflammation  of  the  mputh 
and  fauces.  There  is  a  septic  type  of  temperature,  and  the 
patients  have  a  peculiar  waxy-yellow  appearance,  paler 
than  the  colour  of  pernicious  anaemia.  Hcemorrhage.s 
from  the  mucous  surfaces  under  the  skin  and  into  the  retina 
are  the  rule.  There  is  enlargement  (usually  slight)  of  the 
cervical  glands,  but  the  glands  elsewhere  often  have  no  time 
to  grow  big  before  death  ends  the  case.  The  spleen  is 
generally  palpable,  and  the  liver  may  be  slightly  enlarged. 

The  Blood  (Fig.  39)  shows  a  very  severe  grade  of  red-cell 
anaemia  (600,000  red  cells  is  no  uncommon  count),  with  a  low 
colour  index.  There  is  a  white  count  of  40,000  to  60,000  (not 
often  higher),  and  of  these  white  cells  about  95  per  cent,  are 
large  lymphocytes. 

The  cases  generally  end  fatally  in  from  ten  days  to  two 
months. 

(d)  PsEUDO -Leukemia.  This  term  should  be  restricted 
to  those  cases  associated  with  rickets,  gastrointestinal 
disturbances,  etc.,  occurring  in  infanfs,  in  mIhcIi  there  is 
splenic  enlargement  accompanied  by  a  definite  red-cell 
aniemia  and  a  big  Icucocytosis.  The  colour  index  is  usually 
low,  but  in  some  few  cases  it  may  be  high.  Blood  films 
show    poikilocytosis    and    polychromatophilia    and    many 


166  MEDICAL  DIAGNOSIS 

normoblasts,  some  with  double  nuclei.  Megalob lasts  are 
present  in  scanty  numbers.  There  is  great  variability  in 
the  white  cells  present  ;  not  infrequently  a  considerable 
number  of  myelocytes  may  be  found. 

(e)  Leukan^mia.  This  name  has  been  given  to  certain 
cases  presenting  the  blood  pictures  of  both  spleno -medullary 
leukaemia  and  pernicious  anaemia.  There  is  a  megalo- 
blastic type  of  blood,  and  at  the  same  time  a  great  leucocy- 
tosis,  consisting  largely  of  myelocytes.  This  condition  must 
not  be  regarded  as  a  separate  clinical  entity ;  the  majority 
of  cases  are  slightly  atypical  spleno -medullary  leukaemias, 
and  the  minority  are  late  stages  of  pernicious  anaemia. 

V.   PURPURA. 

This  consists  of  multiple  haemorrhages  into  the  skin  or 
mucous  membranes  ;  it  is  an  expression  of  some  toxic  or 
septic  process,  and  is  therefore  symptomatic.  Clinically  it 
is  customary  to  recognise  several  forms  of  purpura  : — ■ 

(a)  Purpura  Simplex,  where  the  haemorrhages  are  into 
the  skin. 

(b)  Purpura  Hemorrhagica,  where  there  is  bleeding 
from  the  mucous  surfaces. 

Both  these  forms  are  liable  to  occur  in  septicaemia, 
pyaemia,  leukaemia,  and  Bright's  disease,  and  in  the  malig- 
nant forms  of  the  specific  infective  diseases,  such  as  small-pox, 
scarlet  fever,  measles,  etc. 

(c)  Purpura  Rheumatica  (Schoenlein's  Disease).  It  is 
still  doubtful  whether  this  condition  is  really  connected  with 
true  rheumatism.  It  is  met  with  in  children,  and  consists  in 
minute  subcutaneous  haemorrhages,  most  commonly  on  the 
extremities,  accompanied  by  pain  and  swelling  in  one  or 
more  joints.  Inflammation  of  the  fauces  is  not  uncommon 
and  slight  pyrexia  is  the  rule. 

{d)  Henoch's  Purpura.  Children  are  principally  affected  ; 
there  are  purpuric  patches  on  the  skin,  swelling  of  the  joints, 
and  severe  abdominal  pain,  with  vomiting  and  constipation. 
Later  on  there  are  haemorrhages  from  the  mucous  membranes, 
especially  of  the  bowel.  Splenic  enlargement  and  haemor- 
rhagic  nephritis,  or  at  least  haematuria,  are  not  uncommon 


DISEASES    OF   THE    BLOOD  167 

accompaniments  of  this  malady.  The  abdominal  symptoms 
are  produced  by  haemorrhage  into  the  muscle  coat  of  the 
intestine.  Henoch's  purpura  has  been  mistaken  for  intus- 
susception, which,  indeed,  it  may  cause.  The  joint  pains, 
haematuria,  and  subcutaneous  haemorrhages  should,  however, 
prevent  this  mistake. 

(e)  Purpura  Fulminans.  This  is  a  rare  form  of  purpura 
affecting  infants  in  the  first  few  weeks  of  life.  There  are 
spreading  subcutaneous  haemorrhages  which  soon  involve  an 
entire  limb  or  even  several  limbs.  These  become  swollen, 
tender  and  purple  or  even  black.  There  are  no  haemorrhages 
from  the  mucous  membranes.  The  child  dies  in  a  few 
days  with  signs  of  severe  septic  infection. 

Diagnosis.  The  diagnosis  of  purpura  is  easy,  but  it  is  not 
always  so  simple  to  demonstrate  the  cause  of  the  purpura. 
A  blood  examination  will  show  such  conditions  as  Leukoemia 
or  Pernicious  ancemia. 

Scurvy  is  indicated  by  the  condition  of  the  gums  and  the 
pain  and  swelling  in  the  calves  of  the  legs. 

Septiccemia  will  be  diagnosed  by  some  primary  focus,  such 
as  osteomyelitis  or  ulcerative  endocarditis  ;  and  BrighVs 
disease  by  the  condition  of  the  urine  and  the  heart. 

The  haemorrhagic  or  malignant  forms  of  the  specific  infec- 
tive diseases  can  often  only  be  diagnosed  by  the  presence  of 
an  epidemic,  the  history  of  exposure  to  infection,  or  the  fact 
that  some  one  else  becomes  infected  from  the  patient. 

In  all  forms  of  purpura  it  can  be  shown  that  there  is  a 
great  diminution  in  the  number  of  the  blood  platelets. 
Normally  there  are  about  250,000  of  these  in  each  cubic 
millimetre  of  blood  ;  in  purpura  they  fall  to  80,000,  or  even 
less. 

There  is  but  little  information  to  be  gained  by  counting 
platelets,  since  purpura  is  a  self-evident  fact,  but  if  it  be 
desired  to  enumerate  them  the  following  technique  can  be 
adopted  : — 

Carefully  clean  the  patient's  finger  and  place  on  it  a  drop 
of  iO  per  cent,  sodium  metaphosphate.  Prick  the  finger 
through  the  drop  and  allow  some  blood  to  mix  with  the 
solution.  Examine  a  drop  of  the  mixture  on  the  Thoma- 
Zeiss  blood  stage,  if  necessary  diluting  further,  and  note  the 


168  MEDICAL  DIAGNOSIS 

relative  number  of  blood  platelets  and  red  blood  cells  present. 
If  now  an  ordinary  red  blood  cell  count  be  done  the  number  of 
platelets  can  readily  be  calculated. 

VI.   SCURVY. 

A  disease  produced  by  prolonged  deprivation  of  fresh 
food.  The  pathology  is  not  understood  ;  but  the  incidence 
of  scurvy  can  be  checked  by  the  administration  of  lemons 
and  limes  to  those  people  who  are  prevented  from  obtaining 
a  sufficiency  of  fresh  food  and  vegetables. 

Symptoms.  Gradual  onset  of  muscular  and  mental 
debility,  swelling  and  sponginess  of  the  gums,  with  haemor- 
rhages from  them  ;  loosening  of  the  teeth  and  foul  breath  ; 
haemorrhages  into  the  skin  and  sometimes  from  the  mucous 
membranes  ;  painful  swellings  of  the  calves  and  beneath 
the  periosteum  of  the  shafts  of  the  long  bones,  and  nyctalopia 
(night  blindness).  There  is  no  pyrexia  and  no  leucocytosis, 
but  anaemia  is  well  marked. 

Diagnosis.  The  diagnosis  can  usually  be  made  with 
certainty  if  there  is  a  history  of  defective  food  supply  and 
if  the  characteristic  changes  in  the  gums  and  in  the  calves 
of  the  legs  are  present. 

Acute  lymphatic  leuJccemia  can  be  distinguished  by  its 
blood  picture. 

Mercurial  poisoning  can  be  diagnosed  from  the  history. 

Congenital  syphilis  can  be  eliminated  by  performing  a 
Wassermann  reaction  on  both  the  child  and  its  parents. 

Infantile  scurvy  (Scurvy  rickets)  is  a  disease  occurring 
principally,  but  not  exclusively,  in  children  who  have  been 
fed  on  artificial  foods.  It  may  be  associated  with  rickets. 
The  symptoms  and  signs  are  those  of  ordinary  scurvy  with 
the  addition  sometimes  of  separation  of  the  epiphyses. 

VII.   SPLENIC  ANJEMIA 

This  disease  consists  of  a  steadily  progressive  red-ceU 
anaemia  with  a  low  colour  index  and  a  gradually  increasing 
enlargement  of  the  spleen. 

The  most  characteristic  feature  of  the  blood  picture  is  a 


DISEASES   OF  THE   BLOOD  169 

leucopenia  ;  the  white  cells  usually  number  under  4,000  per 
cubic  millimetre. 

In  the  later  stages  haemorrhages  from  the  mucous  surfaces 
(especially  the  stomach)  are  common. 

Three  tj^es  of  splenic  anaemia  are  sometimes  described — 
the  adult  type,  the  infantile  type,  and  Gaucher's  type. 

In  the  Adult  type  men  seem  to  be  aifected  more  often  than 
women  ;  the  disease  usually  starts  between  twenty  and  forty, 
and  the  tendency  is  towards  a  chronic  course. 

The  Infantile  type  (so  called)  is  quite  a  different  condition, 
and  has  been  described  under  the  heading  of  "  Pseudo- 
Leuksemia."  At  the  same  time  the  adult  type  can  and  does 
occur  in  childhood,  sometimes  with  a  familial  incidence. 

Gaucher's  type  is,  in  all  probabihty,  a  primary  endothe- 
lioma of  the  spleen. 

For  the  differential  diagnosis  of  Splenic  anaemia  vide 
Spleen,  Diseases  of,  p.  179. 

VIII.   LYMPHADENOMA  (Hodgkin's  Disease). 

The  clinical  features  of  lymphadenoma  are  a  progressive 
and  diffuse  enlargement  of  the  lymphatic  glands  through- 
out the  body,  enlargement  of  the  spleen,  and  anaemia  of  the 
chlorotic  type. 

All  ages  are  liable,  but  the  majority  of  cases  occur  in 
the  first  half  of  life.  Men  are  more  often  affected  than 
women. 

The  glandular  enlargements  are  usually  first  noticed  in  the 
cervical  region,  then  in  the  axilla,  and  then  in  the  groin. 
The  mediastinal  and  lumbar  glands  are  frequently  involved. 
At  first  the  glands  remain  discrete,  but  after  a  while  they 
fuse  into  large  masses.     Suppuration  is  very  rare. 

The  splenic  enlargement  is  rarely  so  great  as  in  splenic 
anaemia  or  myelogenous  leukaemia. 

The  blood  is  not  characteristic  ;  there  is  a  progressive 
ana>mia  with  a  low  colour  index.  The  white  cells  may  be 
unaltered,  or  they  may  show  a  relative  lympliocytosis  ;  some- 
times there  is  a  distinct  polymorphonuclear  leucocytosis, 
but  this  may  be  attributable  to  secondary  infection.  Death 
may  occur  from  exhaustion   or  from   pressure   effects   on 


170  MEDICAL  DIAGNOSIS 

the  trachea,  oesophagus,  etc.,  by  the  enlarged  mediastinal 
glands. 

The  pathology  of  lymphadenoma  is  obscure  ;  it  has  been 
thought  by  Continental  observers  to  be  due  to  the  tubercle 
bacillus,  but  this  view  is  not  accepted,  though  it  is  estab- 
lished that  tuberculosis  sometimes  follows  lymphadenoma. 

Quite  recently  a  bacillus  of  lymphadenoma  has  been 
described  morphologically  resembling  the  tubercle  bacillus, 
but  this  work  lacks  confirmation  up  to  the  present. 

The  diagnosis  of  lymphadenoma  from  other  varieties  of 
lymphatic  gland  enlargement  may  be  difficult.  When  prac- 
ticable a  gland  should  be  excised  and  submitted  to  micro- 
scopical examination. 

The  structure  of  a  lymphadenomatous  gland  is  fairly 
characteristic  :  there  is  great  increase  in  fibrous  gland 
reticulum,  a  diminution  of  lymphoid  elements,  and  the 
presence  of  big  cells  containing  two  or  four  central  nuclei 
(lymphadenoma  cells).  Large  mononuclear  cells  are  also 
seen.  Tuberculosis  and  lymphosarcoma  can  also  be  readily 
distinguished  by  this  method  (biopsy)  ;  indeed,  in  early 
cases  it  may  be  impossible  to  differentiate  tuberculous 
adenitis  from  lymphadenoma  by  any  other  means.  As  a 
general  rule  there  is  less  anaemia  in  tubercle,  the  spleen  is 
not  enlarged,  and  the  glandular  affection  is  more  likely  to 
be  restricted  to  one  group  of  glands.  In  later  cases  the 
tendency  for  tuberculous  glands  to  break  down  is  a  very 
important  diagnostic  point  {vide  also  p.  102). 

IX.  HAEMOPHILIA. 

In  this  disease  there  is  a  tendency  towards  excessive 
bleeding  after  any  injury  however  trivial,  and  also  for  the 
occurrence  of  apparently  spontaneous  haemorrhages  into  the 
joints. 

The  condition  is  hereditary  :  it  is  conveyed  by  the 
daughters  of  bleeders,  who  do  not  themselves  suffer  ;  on 
the  other  hand,  the  male  bleeder  does  not  transmit  the 
tendency. 

Haemophilia  is  supposed  to  depend  upon  a  deficient 
coagulation  power  in  the  blood  and  a  congenital  delicacy 


DISEASES    OF   THE   BLOOD  171 

in  the  blood  vessels.  In  our  opinion  the  methods  now  in 
use  for  testing  the  coagulation  point  of  the  blood  are  not  of 
sufficient  delicacy  to  be  of  diagnostic  value. 

The  diagnosis  is  easy,  especially  if  the  patient  is  a  man 
and  there  is  a  history  of  prolonged  bleeding  after  tooth 
extraction  or  shaving  cuts  or  other  trifling  injury. 

An  inquiry  as  to  possible  hsemophiha  may  elucidate  some 
cases  of  sudden  and  severe  swelling  of  a  joint  accompanied 
by  great  pain  from  distension. 


CHAPTER   II 

DISEASES    OF    THE    DUCTLESS    GLANDS 

I.   DISEASES  OF  THE  THYROID. 

A.  Myxcedema.  The  characteristic  symptoms  of  this 
condition  are  produced  by  deficiency  in  the  internal  secre- 
tion of  the  thyroid  gland. 

In  the  majority  of  cases  the  thyroid  gland  is  smaller  than 
normal  ;  occasionally  it  may  be  enlarged  by  cyst  formation 
or  excess  of  fibrous  tissue,  but  in  all  cases  there  is  loss  of 
secretory  tissue.  Complete  thyroidectomy  is  followed  by 
myxcedema  in  a  considerable  proportion  of  cases.  The 
disease  is  much  more  common  in  women  than  men,  it  usually 
appears  between  the  ages  of  30  and  50,  and  is  predisposed 
to  by  excessive  child-bearing. 

An  hereditary  influence  can  be  traced  in  some  of  the  cases. 
Occasionally  exophthalmic  goitre  may  be  followed  or  even 
accompanied  by  myxcedema. 

The  Signs  and  Symptoms  are  : — A  malar  flush,  but  pallor 
elsewhere,  dryness  of  the  skin,  absence  of  perspiration  and 
loss  of  hair.  There  is  a  gradual  increase  in  general  bulkiness, 
with  swelling  of  the  skin  of  the  face,  of  the  tongue,  mouth, 
nose  and  lips.  There  is  broadening  of  the  hands  and  feet; 
sluggishness  of  movements  ;  diminished  mentality  and 
powers  of  speech  ;  thick,  husky  voice  ;  a  subnormal  tem- 
perature associated  with  a  definite  feeling  of  chilliness  ; 
loss  of  memory  ;  and  in  extreme  cases  definite  delusional 
insanity.  Despite  the  general  swelling  of  the  subcutaneous 
tissues,  there  is  no  true  oedema  and  no  pitting  on  pressure. 

The  course  of  myxcedema  is  very  chronic  ;  even  if 
untreated,  the  patient  usually  dies  of  some  intercurrent 
malady. 

The  diagnosis  is  not  difficult  in  well-marked  cases. 
Chronic  parenchymatous  nephritis  should  be  distinguished 


DISEASES   OF   THE   DUCTLESS    GLANDS       173 

by  the  true  oedema  and  the  urinary  signs,  though  it  must 
be  remembered  that  albuminuria  is  often  present  in 
myxcedema. 

The  mental  dulness,  the  dry  skin,  and  the  loss  of  hair  are 
not  present  in  Bright's  disease. 

Acromegaly  can  be  distinguished  by  the  definite  bony 
enlargements  of  the  hands,  feet,  and  lower  jaw,  as  well  as 
by  the  visual  phenomena,  and  the  absence  of  the  dry  skin, 
scanty  hair,  and  thick  speech  {vide  also  p.  181). 

Should  any  doubt  exist  as  to  the  diagnosis,  thyroid 
extract  (1-5  gr.)  should  be  exhibited;  the  manner  in 
which  myxcedema  reacts  to  treatment  is  highly  charac- 
teristic. 

B.  Cretinism  is  due  to  a  loss  of  thyroid  function  which  is 
either  congenital  or  appears  before  puberty.  It  is  rarely 
noticed  before  the  age  of  six  months.  Predisposing  factors 
are  residence  in  goitrous  districts,  consanguinity  of  parents, 
and  a  family  taint  of  insanity.  ' 

The  Signs  and  Symptoms  are  : — Impaired  development, 
both  mental  and  physical  ;  dry  skin  and  dry,  brittle,  scanty 
hair  ;  swollen,  bloated  face  with  puffy  lips  and  eyelids ; 
large  tongue,  often  protruding  ;  domed  palate  ;  blobby 
nose,  with  depressed  bridge  ;  short,  thick  limbs  ;  open 
fontanelles  and  delayed  dentition  ;  large,  prominent 
abdomen,  and  marked  lordosis.  Those  cases  which  develop 
about  the  age  of  four  or  five  after  a  healthy  infancy  may 
well,  as  suggested  by  Parker,  be  called  "  juvenile  myxce- 
dema." 

The  diagnosis  of  cretinism  is  not  as  a  rule  difficult.  Very 
slight  or  early  cases  can  sometimes  only  be  diagnosed  after 
a  course  of  treatment  with  thyroid  gland. 

Congenital  syphilis  usually  presents  some  characteristic 
features  {vide  p.  73),  but,  if  necessary,  a  Wassermann 
reaction  both  of  the  child  and  its  parents  should  be  done  to 
clinch  the  diagnosis. 

Achondroplasia  may  at  first  sight  be  mistaken  for 
cretinism,  but  the  lack  of  mental  impairment  and  the  pre- 
servation of  mu.scular  power  are  important  points  against 
cretinism.  Further,  the  extreme  shortness  of  the  limbs, 
especially  of  the  proximal  segments,   the  equal  length  of 


174  MEDICAL   DIAGNOSIS 

the  fingers  and  tri-radiate  appearance  of  the  hands,  as  well 
as  the  curved  limbs  and  the  contracted  pelvis,  should 
prevent  error. 

Mongolian  Idiots  sometimes  present  a  superficial  resem- 
blance to  cretins  ;  their  oblique  eyes,  deep  epicanthic 
folds,  and  fissured  tongues  serve  to  distinguish  them  as  a 
rule. 

C.  Exophthalmic  Goitre  (Graves'  Disease).  This  con- 
dition is  due  to  increased  activity  of  the  thyroid  gland  and 
is  the  exact  converse  of  myxoedema. 

Women  are  very  much  more  frequently  affected  than  men  ; 
the  onset  of  symptoms  usually  occurs  between  the  ages  of 
18  and  30.  Predisposing  causes  may  be  fright  or  violent 
emotion. 

The  Signs  and  Symptoms  are  : — Increased  activity  of  the 
skin,  with  ready  perspiration,  acceleration  of  the  cardiac 
action,  with  palpitation,  and  throbbing  of  the  arteries  in  the 
neck ;  a  fine  involuntary  tremor  of  the  extremities  ; 
progressive  emaciation  ;  diffuse  enlargement  of  the  thyroid 
gland,  and  exophthalmos.  Obvious  enlargement  of  the 
thyroid  and  exophthalmos  may  be  delayed  for  some  time 
after  the  other  symptoms  are  well  marked. 

In  connection  with  the  protrusion  of  the  eyeballs  the 
following  signs  are  described  : — 

Von  Graefe's  Sign.  When  the  eyeball  is  rotated  downwards 
the  descent  of  the  upper  lid  is  delayed,  with  the  result 
that  a  band  of  sclerotic  is  visible  between  the  iris  and  the 
upper  eye-lid. 

Stellwag's  Sign.  Retraction  of  the  upper  lid  to  such  an 
extent  that  it  does  not  descend  at  all. 

Mobius'  Sign.  Lack  of  power  of  convergence  for  accom- 
modation purposes. 

The  tachycardia  leads  to  dilatation  of  the  heart  ;  systolic 
murmurs,  both  apical  and  basal,  are  often  heard. 

Certain  complications  are  of  importance.  Diarrhoea 
and  vomiting  may  be  very  troublesome,  as  may  pruritus. 
Pigmentation  of  the  skin,  either  localised  or  diffuse,  is 
often  seen  ;  patches  of  solid  oedema,  usually  transient, 
have  been  described.  The  nervousness,  irritability  of 
temper,   and    excitability    which   are  symptomatic    of   the 


DISEASES    OF   THE   DUCTLESS   GLANDS       175 

disease   may  culminate  in  acute  mania.     Sclerodermia  or 
myxoedema  may  follow  Graves'  disease. 

Glycosuria  and  albuminuria  are  sometimes  present. 
The  Diagnosis  presents  no  difficult}^  when  the  signs  are 
well  marked  ;  it  is  important  to  remember  that  exophthalmos 
and  thjToid  enlargement  are  not  invariably  present. 

The  temporary  thyroid  enlargement,  with  a  slight  feeling 
of  choking,  which  is  sometimes  present  about  the  age  of 
puberty,  should  not  be  mistaken  for  Graves'  disease,  though 
it  may  develop  into  it. 

A  thyroid  adenoma  is  more  likely  to  be  recognisable 
as  a  tumour  in  some  part  of  the  thyroid  gland,  whilst  the 
exophthalmic  goitre  is  a  diffuse  enlargement  of  the  whole 
gland,  including  the  isthmus.  In  a  very  few  cases  the  en- 
largement has  been  limited  to  one  lobe  of  the  gland. 

An  "  endemic  goitre  "  consists  of  a  diffuse  parenchymatous 
enlargement  of  the  thyroid  gland,  but  is  not  accompanied 
by  any  of  the  signs  of  Graves'  disease.  Such  goitres  inay 
be  simple,  cystic,  or  fibrous. 

Very  early  cases  of  exophthalmic  goitre  may  present 
great  difficulty.  Great  importance  must  be  paid  to  the 
tremor  and  the  cardio-vascular  signs.  Both  tachycardia 
and  tremor  may,  however,  be  due  to  hysteria. 

The  disease  tends  to  run  a  very  chronic  course  ;  in  about 
20  per  cent,  of  all  cases  there  is  a  complete  recoverj^  and 
in  a  further  30  per  cent,  the  disease  becomes  arrested  after 
a  certain  point ;  in  the  remainder  the  patients  continue  to 
get  slowly  worse. 

Very  occasionally  an  acute  form  of  Graves'  disease  is 
met  with  in  which  the  disease  progresses  so  rapidly  that  death 
takes  place  in  a  few  months,  or  even  weeks,  from  the  onset 
of  symptoms. 

II.   DISEASES  OF  THE  THYMUS. 

At  birth  the  thymus  gland  weighs  13  grms.,  under  ordi- 
nary circumstances  it  increases  in  size  for  the  first  twelve 
or  fifteen  years  of  life,  at  which  age  its  weight  is  about 
27  grms.  After  this  it  gradually  atrophies,  until  by  the 
twenty-fifth  year    it   has   practically   disappeared.     lender 


176  MEDICAL  DIAGNOSIS 

certain  circumstances  it  may  persist  or  be  of  abnormal 
size. 

One  of  the  most  important  conditions  associated  with  an 
enlarged  thymus  is  "  Status  Lymphaticus,"  in  which  there  is 
lymphoid  hj^perplasia  throughout  the  entire  body. 

Status  lymphaticus  can  hardly  be  diagnosed  clinically 
unless  there  is  enlargement  of  the  cutaneous  or  mesenteric 
glands.  In  rare  cases  the  thymus  may  be  so  enlarged  as  to 
give  an  increased  area  of  dulness  over  the  manubrium 
sterni,  and  sometimes  it  is  supposed  to  cause  dyspnoeic 
attacks  from  pressure  on  the  trachea  (thymic  asthma).  It 
is  a  recognised  cause  of  sudden  death,  and  also  of  death  while 
under  the  influence  of  an  anaesthetic.  Patients  with  status 
lymphaticus  nearly  always  have  globular  dilated  hearts. 

The  thymus  persists  in  cases  of  exophthalmic  goitre, 
myasthenia  gravis  and  usually  epilepsy,  acromegaly,  and 
lymphatic  leukaemia. 

It  has  been  suggested  that  mediastinal  lymphosarcoma 
may  often  arise  in  a  persistent  thymus  gland  or  in  the 
remnants  of  the  thymus  gland. 

III.    DISEASES  OF   THE  SUPRARENAL  BODIES. 

A.  Addison's  Disease  is  in  the  great  majority  of  cases  due 
to  tuberculosis  of  the  suprarenal  glands  ;  very  rarely  it 
may  be  produced  by  simple  atrophy,  malignant  disease,  or 
pressure  from  without.  There  are  two  theories  as  to  the 
pathology  of  the  condition  : — 

(i.)  That  it  depends  on  a  loss  of  function  of  the  suprarenal 
bodies,  with  the  result  that  the  body  is  deprived  of  their 
internal  secretion. 

(ii.)  That  it  is  an  affection  of  the  abdominal  sympathetic 
nervous  system. 

Men  are  more  liable  than  women,  and  the  disease  usually 
starts  in  the  third  or  fourth  decades  of  life. 

Signs  and  Symptoms.  The  onset  is  gradual,  with  debility 
and  muscular  weakness,  pigmentation  of  the  skin,  vomiting, 
and  a  weak,  poorly-sustained  pulse.  The  pigmentation  is  most 
characteristic  :  it  varies  from  Ught  yeUow  to  deep  bronze ; 
it  is  most  marked  on  the  exposed  parts,  such  as  the  hands 


DISEASES    OF   THE   DUCTLESS   GLANDS      177 

and  face,  on  the  parts  that  are  normally  inclined  to  be 
pigmented,  such  as  the  genitals,  nipples,  etc.,  and  where 
there  has  been  constant  pressure,  such  as  the  corset  area 
in  women  or  those  parts  in  contact  with  the  braces  in  men. 
The  mucous  membranes  do  not  escape,  and  pigmented  areas 
should  alwaj's  be  searched  for  in  the  mouth  and  conjunc- 
tiva? and,  if  necessary,  in  the  vagina. 

The  muscular  weakness  is  so  marked  as  in  time  to  prevent 
walking  about.  Giddiness  and  sj-ncope  are  common. 
The  blood  pressure  is  extremely  low,  often  from  60  to 
80  mm.  of  mercury. 

The  disease  runs  a  course  of  varying  length  ;  patients 
who  suffer  from  persistent  vomiting  sometimes  die  in  a  few 
months,  others  may  survive  for  several  years.  Death  is 
usually  from  exhaustion  or  from  the  supervention  of  tuber- 
culosis elsewhere. 

The  diagnosis  may  be  very  difficult  in  the  early  stages  ; 
the  most  important  signs  will  be  asthenia,  pigmentation 
and  low  blood  pressure.  Sometimes  there  is  an  increased 
carbohydrate  tolerance  so  that  glycosuria  does  not  result 
from  very  large  doses  of  sugar  {e.g.,  300  —  350  grms.). 

There  are  many  other  causes  of  pigmentation  which  must 
be  excluded  before  making  a  positive  diagnosis  of  Addison's 
disease  in  the  absence  of  other  symptoms,  such  as  : — 

Argyria.  Here  there  is  a  history  of  silver,  whilst  the 
coloration  of  the  pigmented  areas  is  more  grey. 

Arsenic,  especially  in  cases  of  j^^^^^^^ioiis  ancemia  ;  this 
can  be  diagnosed  by  the  history  and  the  blood  picture. 

BrighCs  Disease.  Patients  with  red  granular  kidney  may 
become  very  deeply  pigmented  indeed.  The  high  blood 
pressure  and  the  absence  of  pigment  in  the  mucous  mem- 
branes will  prevent  a  diagnosis  of  Addison's  disease  being 
made. 

Chloasma  uterinum,  e.g.,  in  pregnancy  or  uterine  disease, 
can  be  detected  by  appropriate  examination. 

Cirrhosis  of  the  liver  in  the  later  stages  is  often  accom- 
panied by  extensive  pigmentation,  but  it  is  usually  due  to 
an  obvious  jaundice,  as  shown  by  the  sclerotics  and  the 
urine. 

Exojjhfhahnic  goitre  may  be  accompanied  by  considerable 

M.D.  12 


178  MEDICAL   DIAGNOSIS 

pigmentation,  but  the  characteristic  signs  of  the  disease 
will  be  present. 

Pediculosis  and  dirt  may  produce  extreme  discoloration 
of  the  skin  (not  the  mucous  membranes).  This  is  only 
met  with  in  tramps  and  in  the  lowest  social  grades. 

Abdominal  tumours  may  be  accompanied  by  deep  pig- 
mentation, but  careful  examination  may  reveal  the  tumour, 
and  the  history  will  not  be  that  of  Addison's  disease. 

Certain  women,  especially  brunettes,  become  pigmented 
for  no  apparent  reason  and  without  impairment  of  health  ; 
more  often  shght  pigmentation  in  women  may  be  attributed 
to  constipation  and  auto -intoxication  or,  if  their  age  is 
appropriate,  to  the  menopause. 

In  cases  of  doubt  the  special  tests  for  tuberculosis  may 
be  of  assistance  {vide  p.  105). 

B,  Malignant  tumours  of  the  suprarenal  bodies  are  rare, 
but  when  they  do  occur  are  sometimes  accompanied  by 
striking  signs  of  over-activity  of  these  glands,  namely, 
hyper -trichosis,  extreme  sexual  precocity,  high  blood- 
pressure  and  glycosuria.  These  phenomena,  developing  in 
a  young  child,  might  suggest  the  correct  diagnosis. 

C.  Haemorrhage  into  the  suprarenal  bodies  (acute 
haemorrhagic  adrenalitis)  is  a  rare  cause  of  death ;  the 
clinical  features  are  asthenia,  emaciation,  low  blood-pressure 
and  exhaustion. 


IV.  DISEASES  OF  THE  SPLEEN. 

The  spleen  is  situated  beneath  the  ninth,  tenth  and 
eleventh  left  ribs,  separated  from  them  by  the  diaphragm ; 
its  long  axis  is  along  the  tenth  rib,  and  occupies  the  middle 
third  of  the  axilla.  It  is  not  palpable  in  health.  Small 
enlargements  can  sometimes  be  made  out  by  careful  per- 
cussion ;  moderate  enlargements  can  be  appreciated  by 
pushing  the  tips  of  the  fingers  up  underneath  the  left  costal 
margin,  when  the  lower  pole  of  the  spleen  may  be  felt. 

Great  enlargements  cause  a  tumour  of  varying  size  to 
appear  in  the  abdomen  :  it  proceeds  from  under  the  ribs 
downwards   and   forwards,  keeping    mostly  to  the    left    of 


DISEASES   OF   THE   DUCTLESS    GLANDS      179 


the  abdomen,  but  often  reaching  the  umbiHcus  ;  its  lower 
extremity  is  rounded,  and  there  is  a  notch  in  its  anterior 
border.  It  is  not  possible  to  get  above  it  ;  it  seems  very 
superficial  ;  it  is  dull  to  percussion,  and  the  dulness  is 
continuous  with  the  ordinary  splenic  dulness. 

A  splenic  tumour  moves  with  respiration. 

The  most  likely  tumour  to  mistake  for  splenic  enlargement 
is  a  renal  tumour.  This  is  more  deeply  situated  in  the  loin  ; 
it  does  not  move  so  freely  with  respiration  (unless  it  be  a 
movable  kidnej-,  when  it  may  be  possible  to  get  above  it), 
and  there  is  usuallj^  a  resonant  band,  due  to  a  distended 
colon  over  the  tumour.  There  is  no  notch,  and,  unless  it 
is  very  large,  the  tumour  does  not  appear  to  grow  out  from 
under  the  ribs  as  does  the  enlarged  spleen. 

Carcinoma  of  the  fundus  of  the  stomach  may  suggest 
a  splenic  tumour  ;  its  great  irregularity  and  the  absence 
of  notch,  as  well  as  the  symptoms  of  mahgnant  disease 
and  the  examination  of  the  gastric  contents,  will  usually 
suffice  to  establish  the  diagnosis. 

The  following  table  suggests  the  more  common  causes  of 
splenic  enlargement  and  the  means  of  diagnosing  them  : — 

A.  Slight  Enlargements.     Specific  Infective  Diseases,  as  : — 

Enteric  fever  .  .  .  .  1 

Pneumonia     .  . 

Malta  Fever  .  . 

Typhus 

Intestinal  Anthrax  (splenic 

fever) 
Relapsing  fever 


Evidence  of  the  various  in- 
fections concerned. 


r 


Chronic  Venous  Congestion . .  \ 

[ 

B.  Moderate  Enlargements. 
Pernicious  Anemia  .  .  .  .  ] 

Acute  Lymphatic  Leukaemia  ' 
Lymphadenoma       (may     be  j 

great  enlargement) 
Infarction 


Apart  from  coexistent  in- 
farction, the  spleen  is  but 
httle  enlarged  from  this 
cause. 

Blood  examination. 
1  And 

r  Glandular  swellings. 


Evidence  of  cardiac  disease. 
12—2 


]80 


MEDICAL  DIAGNOSIS 


B.  Moderate  Enlargemenis- 

Thrombosod  Splenic  or  Portal 
Veins 

Accompanying  Cirr-  [  Portal 

hosis  of  Liver. 
Weil's  Disease 
Rachitis 
Congenital  Syphilis 


Biliary 


-continued. 

[   Sudden    onset    of     spleno- 
-;        niegaly  with  ascites  and 

I        hsematemasis. 

^  Evidence  of  cirrhosis. 


1 


{vide  p.  384). 


f-  Evidence  of  primary  disease. 


Malignant  Disease  (rare] 


Tuberculosis  frarel 


Malaria    (may 
largement) .  . 


be   great   en- 


Splenomegaly  with  Acholuric 
Jaundice  (rare) 


C.  Great  Enlargements. 

Splenic  Anaemia 

Spieno-medullary  Leukaemia 

Chronic  Lymphatic  Leu- 
kaemia 

Splenomegaly  with  Polycy- 
thsemia 


Trypanosomiasis 


Kala  Azar 


J 

[  Evidence  of  primary  focus 

!  (primary    malignant    dis- 

j  ease  in  spleen  is  extremely 

[  rare). 

f  Evidence      of      generalised 

{  tuberculosis  or  of  tuber- 

L  culous  peritonitis. 

f  History  :    signs    of  Malaria 

\  and  presence  of  parasites 

[  in  the  blood. 

f  Negative  blood  except  for 

j  increased  friability  of  red 

I  cells,  yellow  coloration  of 

I  skin,  absence  of  bilirubin 

I  in    urine,    familial    inci- 

[^  dence. 


[   Blood 

I    Examination. 

j  ]  And 

J  [  Cyanosis. 

f  Residence  in  West  Africa  : 

{        presence  of  trypanosomes 

[       in  blood. 

f  History  of  residence  abroad 

[  (especially  Assam),  splenic 
puncture,  and  discovery 
of         Leishman-Donovan 

L       bodies  in  the  blood. 


BLSEAHES    OF   THE   DUCTLESS   GLANDS      181 

V.   DISEASES  OF  THE  PITUITARY  BODY. 

A.  Acromegaly.  It  is  convenient  first  to  describe  acro- 
megaly, which  is  cHnically  the  best  l^nown  of  the  pituitary 
disorders.  This  is  a  condition  associated  with  disease  of  the 
''pituitary  body  "  and  beheved  to  be  due  to  hyper-pituitarism 
that  is  to  say,  to  excess  of  some  internal  secretion  of  this 
glancL 

The  disease  usually  shows  itself  in  the  third  or  fourth 
decades,  and  practically  never  starts  after  the  age  of  forty. 
It  is  more  common  in  women  than  in  men. 

The  characteristic  signs  are  dependent  upon  an  overgrowth 
or  diffuse  hypertrophy,  including  all  the  tissues,  of  the  hands 
and  feet  and  certain  other  parts.  The  wrists  and  ankles  are 
involved,  but  not  the  forearms  or  legs.  The  result  is  a 
curious  spade-like  appearance  of  the  hands  and  feet.  The 
greatest  increase  in  size  is  often  in  the  thumbs  and  great  toes. 
The  head  is  increased  in  size  as  a  whole,  but  the  change  is 
particularly  marked  in  the  lower  jaw,  w^hich  sticks  out  in 
front  of  the  upper  one,  w^hile  the  teeth  become  separated 
from  each  other.  The  tongue,  eyelids,  and  nose  may  be  very 
much  hypertrophied.  The  skin  tends  to  be  greasy,  and  the 
natural  lines  in  it  are  greatly  accentuated. 

In  50  per  cent,  of  all  cases  there  are  definite  visual  changes, 
the  most  common  being  bi -temporal  hemianopia  or  optic 
atrophy.  In  extreme  cases  the  ribs,  sternum,  and  clavicles 
may  be  hypertrophied.  Kyphosis  is  common.  Gigantism 
is  generally  identical  with  acromegaly  which  has  developed 
during  the  period  of  natural  growth. 

The  clinical  picture  of  acromegaly  is  fairly  distinctive  ;  it 
jnust  not  be  mistaken  for  the  following  : — 

(i.)  Osteitis  Deformans  (Paget's  Disease).  This  is  a 
rare  disease  of  unknown  causation,  characterised  by  a 
rarefying  osteitis  of  certain  bones.  The  skull  becomes  of 
great  size,  and  causes  the  face  to  have  a  triangular-  shape 
with  the  base  of  the  triangle  upwards. 

There  is  also  a  dorso-cervical  kyphosis  and  hypertro]>hy 
(ap])arent)  of  the  clavicles,  humeri,  and  femora,  the  latter 
becoming  bent  forwards.  There  appears  to  be  a  tendency 
for  sufferers  from  this  disease  to  develop  malignant  tunu)urs  ; 


182  MEDICAL  DIAGNOSIS 

if  they  live  long  enough  there  is  a  veiy  definite  diminution  in 
height,  due  to  the  kyphosis  and  the  bending  of  the  thigh 
bones. 

There  is  some  evidence  that  osteitis  deformans  is  in  some 
way  connected  with  syphilis  ;  certainly  many  patients  give  a 
positive  ^Vassermann  reaction. 

(ii.)  Leontiasis  Ossea.  A  rare  condition  characterised  by 
overgrowth  of  the  bones  of  the  head  and  face,  especially 
of  the  superciliary  ridges  and  malar  bones. 

The  pathology  is  unknown  ;  occasionally  it  may  coexist 
with  osteitis  deformans. 

(iii.)  Hypertrophic  Pulmonary  Osteo-arthropathy .  This 
condition  is  associated  with  chronic  pulmonary  disorders, 
such  as  emp3^ema,  bronchial  asthma,  emphysema,  and  the 
like.  Occasionally  it  may  follow  syphilis  and  heart  disease. 
It  is  characterised  by  overgrowth  of  the  hands  and  feet  and 
also  the  ends  of  the  long  bones.  The  most  striking  change 
is  in  the  terminal  phalanges,  which  become  noticeably 
thickened  and  splayed  out  ;  the  nails  are  large  and  curved 
and  show  longitudinal  striation. 

The  localisation  and  appearance  of  the  overgrowth  is 
not  in  the  least  like  acromegaly,  while  the  presence  of  a 
pulmonary  or  cardio-vascular  lesion  should  settle  the 
diagnosis. 

(iv.)  MyxoRdema  {vide  p.    172). 

B.    Pituitary  Disorders  as  a  whole. 

The  Pituitary  body  consists  of  three  parts  : — 

(i.)  An  anterior  lobe,  which  is  formed  by  an  up -growth 

from  the  pharynx. 

(ii.)  A  posterior  lobe,  which  is  a  down-growth  from  the 

central  nervous  system. 

(iii.)  A  "pars  intermedia,"  which  connects  the  anterior 

and    posterior    lobes,    but    which,    histologically,    is    the 

anterior  part  of  the  posterior  lobe. 

Clinically  it  is  convenient  to  include  in  the  comprehensive 
term  "  Dyspituitarism  "  all  the  various  conditions  which  are 
known  or  believed  to  depend  on  alterations  in  the  functions 
of  the  pituitary  gland. 

It  is  obvious  that  the  gland  may  err  in  the  direction  of 
either  over-  or  under-  activity,  just  as  does  the  th3rroid  gland, 


DISEASES   OF   THE   DUCTLESS   GLANDS       183 

but  ill  the  case  of  the  pituitary  body  the  outlook  is  obscured 
at  present  by  lack  of  accurate  knowledge  concerning  the 
respective  functions  of  the  anterior  and  posterior  lobes  and 
the  different  ways  in  which  these  may  be  affected  by  disease. 
For  example,  it  is  possible  that  we  might  get  over-action  of 
the  anterior  lobe  combined  with  deficiency  of  the  posterior 
lobe,  or  vice  versd,  or  both  lobes  might  be  either  too  vigorous 
or  atrophic  at  one  and  the  same  time. 

Nevertheless,  it  is  probable  that  the  pituitary  body  is 
iLsuallij  affected  as  a  whole,  and  it  is  possible  to  give  a  list 
of  signs  and  symptoms  which  may  indicate  respectively 
hyper-  and  hypo-  pituitarism. 

It  is  important  to  remember  that,  apart  from  invasion  of 
the  pituitary  body  by  malignant  growths  (in  which  case 
progressive  hypo -pituitarism  may  be  the  first  local  sign), 
the  initial  symptoms  in  the  commonest  forms  of  pituitary 
disease  (struma  or  adenoma)  are  likely  to  be  indicative  of 
over  action,  but  that  as  the  disease  progresses  the  essential 
properties  of  the  gland  are  likely  to  be  abolished  by  pressure 
or  atrophy,  so  that  hypo -pituitarism  may  supervene. 

This  may  explain  those  cases  of  acromegaly  in  which  no 
pituitary  enlargement  has  been  found  after  death,  for,  if 
the  over-action  has  continued  sufficiently  long  to  produce 
bony  changes,  these  will  persist  even  when  the  under-action 
becomes  apparent  and  so  the  actual  hypo-pituitarism  of  the 
later  stages  of  the  disease  may  be  missed. 

The  symptoms  of  hyper -pituitarism  are  in  the  main  those 
that  have  been  described  under  the  heading  "  Acromegaly  "  ; 
while  if  the  change  occurs  before  the  epiphyses  have  united, 
gigantism  precedes  the  acromegaly,  which  will  develop  later 
unless  spontaneous  arrest  of  the  morbid  process  takes  place. 

These  acromegalic  signs  are  believed  to  indicate  an 
increased  function  of  the  anterior  lobe  of  the  pituitary  body. 

Hyper-trichosis,  sexual  precocity,  high  blood  ])ressure, 
and  excessive  activity  in  the  direction  of  carbohydrate 
metabolism  (leading  to  hyper-gl3'ca?mia  and  glycosuria) 
are  possible  signs  of  over-activity  of  the  posterior  lobe. 

Hypo  pituitarism  may  present  the  following  features 
(cf.  the  Fat  Boy  of  "  Pickwick  ")  :  — 

Adiposity,  drowsiness,  smooth  skin,  loss  of  hair  in  axilhe 


1S4  MEDirAL  DIAGNOSIS 

and  pubic  region,  slow  pulse,  low  blood  pressure,  and  greatly 
increased  carbohydrate  tolerance. 

These  symptoms  are  probably  due  to  insufficiency  of  the 
posterior  lobe. 

A  low  temperature  and  susceptibility  to  cold  may  indicate 
anterior  lobe  insufficiency. 

A  striking  feature  in  many  cases  of  hypo-pituitarism  is  the 
change  in  sexual  characteristics.  Adults  lose  their  sexual 
power  and  develop  reversive  changes  in  their  sexual  appara- 
tus, while  children  remain  infantile  in  growth  and  appearance 
and  never  develop  the  adult  sexual  features.  The  male 
sex  assumes  many  of  the  physical  attributes  of  the  female. 

Hitherto  we  have  mentioned  only  the  glandular  signs  of 
pituitary  tumour. 

The  General  signs  vary  somewhat  from  the  classical  signs 
of  other  cerebral  tumours.  Headache  is  frequently  present 
at  some  time  or  cinother,  but  is  not  so  marked  or  so  constant 
as  in  ordinary  cerebral  growths.  Vomiting  is  comparatively 
rare. 

Optic  neuritis  may  occur,  but  is  not  nearly  so  common  as 
optic  atrophy.  Sometimes  a  choked  disc  follows  the  optic 
atrophy. 

Certainly  the  most  important  diagnostic  point  is  bi-tem- 
jioral  Jiemianopia ;  this  is  constant  and  may  be  preceded 
by  a  similar  loss  of  colour  vision. 


CHAPTER    III 

DISORDERS   OF   METABOLISM   4.XD    CONSTITUTIONAL 

DISEASES 

I.  DIABETES   MELLITUS. 

Definition.  A  wasting  disease  characterised  by  profound 
disturbance  of  carbohydrate  metabolism,  and  by  the  appear- 
ance of  ghicose  in  the  urine. 

Etiology.  Diabetes  is  predisposed  to  by  a  sedentary  life, 
excessive  brain  work,  and  over-indulgence  in  rich  food  ;  it 
is  most  frequently  seen  in  the  second  half  of  life,  in  the  male 
sex,  and  it  is  common  among  Eastern  races,  especially  the 
Jews.  There  is  a  strong  hereditary  influence.  The  exact 
pathology  of  diabetes  is  still  unknown,  but  certain  facts 
stand  out,  viz  : — 

(i.)  Diabetes  is  accompanied  by  hyper -glyca?mia,  that  is, 
more  than  "2  per  cent,  of  sugar  in  the  blood. 

(ii.)  There  is  a  disability  to  derive  heat-energ;y^  from  the 
circulating  sugar  by  the  exercise  of  tho.se  glycolj^tic  functions 
which  occur  in  healthy  persons. 

(iii.)  The  demand  for  sugar  by  the  tissues  continues, 
notwithstanding  that  they  cannot  utilise  it  when  they  have 
got  it,  and  the  dLsability  of  the  tissues  is  fostered,  if  not 
produced,  by  the  presence  of  hyper -glyc.Tmia. 

(iv.)  A  certain  amount  of  heat  is  necessary  for  continued 
existence— the  bulk  of  this  is  normally  furnished  bV  carbo- 
hydrates ;  therefore,  in  diabetes,  when  carbohydrates 
fail  other  food-stuffs  are  pressed  into  service  for  heat  pro- 
duction. If  enough  heat  is  not  provided  by  the  food  taken 
in,  the  heat  is  obtained  by  breaking  up  the  body  tissues  them- 
selves, and  the  strain  of  this  abnormal  metabolism  is  hrst 
felt  by  the  fats  and  later  by  the  proteids  also.  The  wasting 
of  diabetes  is  partly  explained  in  this  manner. 

(v.)  There  is  a  danger  that  in  these  processes  of  abnoinial 


186  MEDICAL  DIAGNOSIS 

metabolism  certain  bodies  may  be  formed  which  normally 
are  either  absent  or  only  present  in  very  small  amounts, 
and  that  the  excess  of  these  bodies  may  be  directly  harmful 
or  even  lethal  to  the  patient.  These  toxic  bodies  are  largely 
formed  in  diabetes  by  excessive  or  abnormal  fat  destruction, 
and  circulate  in  the  blood  as  acetone,  diacetic  acid,  and 
y8  amido-oxybutyric  acid.  The  presence  of  this  latter  is 
directly  or  indirectly  the  cause  of  diabetic  coma. 

(vi.)  The  most  constant  lesion  in  diabetes  (though  it  is  not 
invariable)  is  a  fibrosis  of  the  pancreas.  Experimental 
extirpation  of  the  pancreas  is  followed  by  diabetes. 

(vii.)  CUnical  diabetes  may  also  be  associated  with  cirr- 
hosis or  other  extensive  disease  of  the  liver  and  lesions 
of  the  brain,  especially  when  situated  in  the  vicinity  of  the 
fourth  ventricle  and  medulla. 

(viii.)  Every  person  has  a  sugar  toleration  point  beyond 
which  the  ingestion  of  further  sugar  is  followed  by  glycosuria. 
The  average  amount  of  sugar  that  can  be  taken  by  an  adult 
without  glycosuria  resulting  is  100 — 200grms.  Some  people 
have  a  very  low  sugar  toleration  point,  but  they  have  not 
necessarily  got  diabetes  ;  this  may  partly  explain  why  it 
is  not  infrequent  to  find  transient  glycosuria  in  elderly  people 
who  are  gouty,  arterio -sclerotic,  and  who  "  do  themselves 
weU,"  though  possibly  arterio -sclerosis  is  itself  a  factor, 
since  it  is  well-nigh  universal  in  true  diabetes. 

(ix.)  A  certain  amount  of  sugar  passes  straight  into  the 
circulation  without  storage  (as  glycogen)  in  the  liver. 

It  is  accepted  that,  in  health,  the  glycogen  stored  up  by 
the  liver  is  set  free  into  the  circulation  as  sugar,  and  that  this 
sugar  is  broken  up  by  glycolytic  enzymes  into  COo  and  water 
and  so  furnishes  heat  energy  to  the  body.  These  enzymes 
are  manufactured  largely  by  the  muscles,  and  to  some  extent 
also  by  the  liver  and  possibly  other  organs,  but  in  order  that 
the  enzyme  may  exercise  its  glycolytic  action  on  the  sugar 
it  must  first  be  activated  by  a  "  hormone."  Possibly  this 
hormone  is  supplied  by  the  internal  secretion  of  the  pancreas. 

In  diabetes,  if  the  pancreas  is  extensively  diseased,  the 
hormone  is  not  forthcoming  and  glycolysis  is  greatly  inter- 
fered with.  Even  if  the  pancreas  is  not  demonstrably 
diseased,  its  nervous  control  may  be  impaired  with  the  same 


DISORDERS   OF  METABOLISM  187 

result.     Cases  of  cerebral  lesions  accompanied  by  glycosuria 
may  perhaps  be  explained  in  this  manner. 

It  is  obvious  that  the  liver  may,  theoretically,  produce 
diabetes  by  turning  its  glycogen  into  sugar  and  discharging 
it  into  the  circulation  more  quickly  than  it  can  be  broken 
up  by  the  tissues  and  in  this  way  producing  a  hyper -gly- 
csemia.  Or  possibly  the  glycogenic  function  of  the  liver 
may  be  upset,  and  sugar  may  pass,  in  excess,  straight  into 
the  blood. 

Hence  an  alternative  theory  has  been  set  forth  which 
assumes  that  diabetes  is  due  to  excessive  mobilisation  of 
sugar  by  the  liver  and  not  to  any  disability  of  the  organism 
to  use  circulating  sugar.  x4ccording  to  this  view  the  out- 
put of  sugar  by  the  liver  is  stimulated  by  the  internal 
secretion  of  the  suprarenal  glands  and  the  activitj'-  of  this 
suprarenal  secretion  is  checked  by  the  internal  secretion  of 
the  pancreas.  Since  the  suprarenal  bodies  have  similar 
properties  to  the  posterior  lobe  of  the  pituitary  ]3o:ly, 
pituitary  glycosuria  can  readily  be  explained  on  this  hypo- 
thesis. Further  the  internal  secretion  of  the  thyroid  body 
is  supposed  to  counteract  the  action  of  the  pancreas  in 
checking  suprarenal  activity  so  that  the  occurrence  of  gly- 
cosuria in  some  cases  of  thyroid  disease  can  be  explained. 

This  theory  is  attractive,  but,  up  to  the  present,  we 
consider  that  the  balance  of  evidence  is  in  favour  of  the 
older  view. 

The  Cardinal  Symptoms  of  Diabetes  are  : — Thirst,  polyuria, 
wasting,  and  hunger.  The  first  three  are  almost  invariable, 
though  there  may  be  latent  periods  or  remissions  in  which  they 
may  not  be  striking.  The  other  manifestations  and  symp- 
toms are  numerous,  and  they  are  of  special  importance,  since 
they  may  give  the  first  clue  to  a  correct  diagnosis  :  they 
arc  : — 

(i.)  OJ  the  Eye.     Cataract,  neuro-retinitis,  and  haemorr- 
hages. 

(ii.)  OJ    the   Skin   and  Mucous   Membranes.     Dryness, 

eczema,  pruritus,  carbuncles,  boils,  and  gangrene.     The 

tongue  is  dry,  glazed  and  "  beefy." 

(iii.)  Of  the  Nervous  System.     Coma,  neuritis,  headache, 

drowsiness,  insomnia  and  paraplegia. 


188  MEDICAL  DIAGNOSIS 

(iv.)  Of  the  Sexual  Organs.     Impotence  and  abortion, 
(v.)  Of  the  Muscles.     Cramp  and  great  weakness, 
(vi.)  Of  the   Lungs.     Tuberculosis    and    chronic   bron- 
chitis. 

(vii.)  Of  the  Blood-vessels.     Arterio -sclerosis, 
(viii.)  Of  the  Kidneys.     Albuminuria. 
The  temperature  of  diabetics  tends  to  be  subnormal,  and 
they  are  nearly  always  constipated. 

The  Urine  is  greatly  increased  in  amount  (it  may  even 
be  passed  to  the  extent  of  ten  to  fifteen  pints  daily  )  ;  it  is 
clear,  pale  and  of  a  high  specific  gravity  (1030 — 1040).  Glucose 
is  present  in  amounts  varying  from  a  trace  to  15  per  cent.  In 
severe  cases  there  may  be  a  smell  of  acetone,  and  both  this 
and  diacetic  acid  may  be  shown  by  appropriate  tests  {vide 
pp.  429- — 431).  Often,  however,  the  patient's  breath  may 
smell  of  acetone  without  there  being  any  present  in  the 
urine.     Not  infrequently  there  is  a  slight  albuminuria. 

The  outstanding  complication  of  diabetes  is  coma,  which 
may  develop  with  great  suddenness,  especially  after  undue 
muscular  exertion.  Coma  is,  however,  more  often  ushered 
in  with  the  important  symptoms  of  drowsiness,  air  hunger, 
and  abdominal  pain  ;  whilst  the  fatty  acids  can  be  found 
in  the  urine  even  though,  as  often  happens,  there  is  a  marked 
fall  in  the  output  of  sugar. 

The  diagnosis  of  diabetes  does  not  present  any  dififtculty 
provided  that  a  routine  examination  of  the  urine  is  made 
in  every  case.  When  a  reducing  body  is  present  in  the 
urine  it  is  first  necessary  to  be  sure  that  it  is  sugar  {vide 
section  on  "  Urinary  Analysis  ").  Having  established  the 
fact  that  sugar  is  present,  the  case  must  be  regarded  as 
potential  diabetes  until  adequate  investigation  has  been 
carried  out  for  at  least  several  weeks.  If  sugar  is  present 
only  on  certain  occasions,  especially  after  a  heavy  meal  of 
carbohydrate,  and  the  patient  is  otherwise  in  perfect  health, 
or  if  there  is  a  small  amount  of  sugar  in  the  urine  of  an 
elderly  and  fat,  gouty,  or  arterio -sclerotic  gourmand,  then 
a  very  favourable  view  may  be  taken,  qua  diabetes,  especially 
if,  in  the  latter  case,  the  sugar  can  be  controlled  by  a  trifling 
adjustment  of  the  diet. 

Cceteris  jjaribus,  the  presence  of  sugar  without  polyuria 


DISORDERS   OF   METABOLISM  189 

and  ill  a  urine  of  low  specific  gravity  is  favourable.  Scien- 
tifically there  can  be  dravi^n  no  hard  and  fast  line  between 
glycosuria  and  diabetes,  and  only  time  and  experience  can 
show  which  cases  are  of  clinical  significance. 

Prognosis.  Nearly  all  the  diabetics  can  make  use  of 
some  carbohydrates,  and  the  prognosis  varies  directly  with 
the  amount  which  the  patient  can,  with  proper  treatment, 
be  educated  to  utilise.  For  the  rest  the  prognosis  varies 
with  the  age,  the  older  the  patient  the  better  the  prognosis. 
In  children  and  young  people  diabetes  is  nearly  always 
quickly  fatal.  "  Acidosis  "  is  always  of  serious  import, 
as  are  carbiuicles  or  gangrene  ;  at  the  same  time  elderly 
patients  may  live  for  years  with  a  constant  acetonuria 
provide!  there  are  no  other  complications  and  adequate 
treatment  can  be  employed. 

II.  DIABETES  INSIPIDUS. 

This  is  an  obscure  disease  characterised  by  the  passAge  of 
very  large  amounts  (up  to  fifty  pints  daily)  of  clear,  pale, 
watery  urine  of  low  specific  gravity,  free  from  sugar  (unless  in 
the  merest  traces)  or  albumin,  and  without  an}^  increase  of 
solids. 

Two  groups  are  recognised  : — First,  those  in  which  there 
is  a  definite  lesion,  such  as  cerebral  syphilis,  a  tumour  of 
the  brain,  or  a  head  injury  ;  and,  secondly,  those  in  which 
there  is  no  discoverable  lesion  (so-called  "  idiopathic  " 
form).  Occasionally  an  hereditary  influence  may  be 
observed. 

As  would  be  expected  from  the  depletion  of  the  system  by 
the  passage  of  so  much  water,  thirst  is  the  outstanding 
symptom  of  diabetes  insipidus. 

The  diagnosis  is  obvious  in  marked  cases,  but  in  the 
slighter  forms  care  must  be  taken  to  exclude  diabetes 
mcllitus,  red  granular  kidney,  hysterical  polyuria,  and  even 
hydrone})hrosis. 

The  prognosis  in  the  symptomatic  form  depends  entirely 
on  the  causative  lesion  ;  in  the  idiopathic  form  it  is  good  as 
regards  life  but  most  uncertain  as  regards  cure.  Some  cases 
recover  spontaneously  ;  others  persist  without  notable 
im])airmont  of  licaltli  foi*  many  years. 


190  MEDICAL  DIAGNOSIS 


III.  GOUT. 


Definition.  A  disorder  of  metabolism  characterised  by  a 
tendency  to  arthritis  with  the  deposition  of  sodium  biurate 
in  the  connective  tissues  of  and  around  the  joints,  and  also 
by  certain  visceral  manifestations. 

Etiology.  The  etiology  of  gout  is  imperfectly  understood, 
but  the  disease  would  appear  to  depend  upon  defective  meta- 
bolism (pj^obably  excessive  oxidation)  plus  impaired  excretory 
power.  It  is  more  common  in  men  than  in  women,  and 
occurs  principally  between  the  ages  of  40  and  65. 

Certain  factors  stand  out  as  predisposing  causes,  notably 
heredity,  over-indulgence  in  food  and  alcohol,  and  lead 
poisoning.  There  is  in  addition  a  nervous  or  mental  factor, 
especially  in  the  determination  of  an  acute  attack.  Certain 
climates  {e.g.,  India  and  to  a  less  extent  America)  seem 
unfavourable  to  the  development  of  gout. 

Uric  acid  is  manufactured  in  the  body,  partly  exogenously 
by  oxidation  of  the  purin  bases,  which  are  in  turn  derived 
from  ingested  nucleo-proteid  (uric  acid  itself  is  tri-oxy- 
purin),  and  partly  endogenously,  from  the  by-products  of 
tissue  katabolism. 

According  to  Sir  William  Roberts  the  bulk  of  the  uric 
acid,  however  formed,  circulates  in  the  blood  as  sodium 
quadriurate,  which  is  a  soluble  salt  but  unstable,  since  it  is 
always  ready  to  take  up  another  atom  of  sodium  and  to 
become  sodium  biurate,  which  is  stable  but  highly  insoluble. 
Further,  while  sodium  biurate  is  soluble  in  distilled  water 
in  the  proportion  of  I  in  1,000,  this  solubility  decreases 
rapidly  if  sodium  salts  be  added  to  the  solution  till  in  water 
containing  •?  per  cent,  of  sodium  bicarbonate  the  biurate  is 
practicably  insoluble. 

If,  then,  there  is  a  temporary  or  permanent  impairment 
of  the  excretory  functions,  there  will  be  an  excess  of  circu- 
lating quadriurate,  which  will  attach  to  itself  an  atom  of 
sodium  from  the  existing  sodium  carbonate  of  the  plasma. 
It  is  reasonable  to  suppose  that  this  transformation  of  quad- 
riurate into  biurate  is  most  likely  to  occur  in  those  regions 
where  there  is  most  sodium  carbonate,  and  there  is  experi- 
mental evidence  to  show  that  cartilage  and  the  synovial 


DISORDERS   OF   METABOLISM  191 

fluids  are  especially  rich  in  this  substance.  The  prevalence 
of  uratic  deposits  in  the  joints  may  thus  be  in  part  explained. 
Another  factor  is  the  stagnation  of  synovial  fluid,  which 
physically  favours  the  deposition  of  circulating  salts. 

The  above  theory  is  given  for  what  it  is  worth  ;  but  it  is 
only  fair  to  say  that  but  little  is  known  concerning  the 
pathology  of  gout,  although  it  is  generally  accepted  that  there 
is  an  excess  of  circulating  uric  acid  (in  some  form  or  another) 
in  gouty  persons  {vide  also  p.  414).  The  inflammatory 
changes  in  gouty  joints  are  thought  to  be  secondary  to  the 
deposition  of  the  sodium  biurate,  and  not  vice  versa. 

Clinical  Features.  Clinically  gout  maybe  acute,  chronic,  or 
metastatic. 

(i.)  Acute  Gout.  For  some  days  there  is  likely  to  be 
irritability  of  temper,  depression,  and  possibly  twinges  of 
pain  in  the  smaller  joints.  The  real  acute  attack  usually 
starts  with  extreme  suddenness,  often  in  the  middle  of  the 
night.  The  most  common  joint  to  be  affected  is  the  ^neta- 
tarso-phalangeal  joint  of  the  right  great  toe,  but  other  joints 
may  be  selected. 

The  pain  is  agonising  ;  the  joint  swells  up  and  becomes 
purple,  shiny,  and  often  cedematous.  At  the  same  time 
there  will  be  constitutional  signs,  such  as  moderate  fever, 
furred  tongue,  constipation,  and  anorexia.  The  urine  is 
scanty  and  high  coloured,  while  the  output  of  uric  acid  is 
temporarily  increased.  After  a  few  hours  the  pain  subsides 
somewhat,  only  to  return  the  next  night.  The  pain  and 
swelling  commonly  disappear  by  the  end  of  the  week.  The 
joint  recovers  its  mobility  perfectly  after  the  first  attack, 
though  repeated  attacks  leave  permanent  structural 
deformity. 

After  an  attack  of  acute  gout  the  general  health  is  particu- 
larly good  for  a  while,  but  each  attack  renders  a  subsequent 
one  more  likely,  and  the  intervals  between  successive  attacks 
grow  less. 

An  acute  gouty  joint  must  not  be  mistaken  for  : — 
(a)  Acnte  Rheumatism  {vide  p.  60). 
{b)  Septic  Arthritis  and  Cellulitis.     The  age  and  history 

of  the  patient,  the  absolutely  sudden  onset,  and  the  absence 

of  a  septic  focus  will  suggest  gout  ;    clinically,  however, 


192  MEDICAL   DIAGNOSIS 

the  resemblance  may  be  very  striking.  Tlie  presence  of 
definite  fluctuation  would  suggest  pus,  as  would  rigors  and 
sweating. 

(ii.)  Chronic  Gout.  Tiiis  is  the  sequel  of  multiple  acute 
attacks.  The  joints  are  deformed  by  massive  deposits  of 
so  lium  biurate,  above  which  the  skin  may  ulcerate  exposing 
hard,  chalky  masses  or  else  soft,  pultaceous,  gruelly  material. 
The  muscles  waste  from  disuse,  and  gross  deformities  occur  by 
over-action  of  certain  muscle  groups. 

Chronic  gouty  arthritis  can  be  mistaken  for  nothing  else, 
for  even  in  the  earliest  cases  there  will  be  the  typical  history 
of  acute  attacks. 

(iii.)  Metastatic  Gout.  Under  this  heading  may  be  grouped 
all  the  diverse  affections  of  various  organs  which  occur,  par 
excellence,  in  gouty  persons  and  many  of  which  may  be 
distinctly  benefited  by  treatment  directed  at  the  underlying 
gouty  state.  These  manifestations  are  naturally  important 
in  so  far  as  they  may  suggest  the  diagnosis  of  gout  apart  from 
an  acute  attack  ;  they  will  be  considered  briefly  under  the 
various  systems  which  they  attack. 

{a)   The  Eye.     Iritis  may  be  of  gouty  origin.     Retinal 
haemorrhages  are  common  in  the  gouty  because  of  the 
associated  renal  and  cardio-vascular  changes. 
Glaucoma  has  been  recorded. 

(6)  The  Skin.  Eczema,  pruritus,  and  boils  may  be  men- 
tioned, in  addition  to  gouty  tophi  in  the  ears  and  elsewhere. 

(c)  The  Cardio-vascular  System.  The  heart  is  hyper- 
trophied  because  of  the  renal  fibrosis  and  high  blood 
pressure.  Fibroid  and  fatty  changes  in  the  myocardium 
are  common,  as  also  are  attacks  of  angina  pectoris. 

(d)  The  Respiratory  System.  Laryngitis  may  be  caused 
by  the  deposition  of  biurate  in  the  cartilages  of  the  larynx. 
Dyspnoea  of  a  paroxysmal  nature  clinically  resembling 
true  bronchial  asthma  and  not  directly  attributable  to 
cardiac  insufficiency  may  occur.  A  renal  (ursemic)  origin 
for  this  seems  probable. 

(e)  The  Nervous  System.  Neuritis  is  not  uncommon, 
and  hemiplegia  from  cerebral  haemorrhage  is  a  frequent 
cause  of  death  in  gouty  persons.  Headaches,  muscular 
cramps,  and  even  gouty  meningitis  are  described. 


DISORDERS   OF   METABOLISM  193 

(/)  The  Urinary  System.  Arterio-sclerosis  and  red 
granular  kidneys  are  the  rule,  with  all  the  symptoms  that 
attend  them  {vide  pp.  446 — 448). 

An  intermittent  glycosuria  is  common. 

The  association  of  urinary  calculus  and  gout  has  long 
been  recognised. 

{g)  The  Alimentary  Tract.  Chronic  pharyngitis  and 
nasal  catarrh  are  often  attributed  to  gout. 

Chronic  dyspepsia.,  with  acute  exacerbations  (bilious 
attacks)  and  obstinate  constipation,  are  of  frequent 
occurrence. 

IV.  RICKETS  (RACHITIS). 

Definition.  A  disorder  of  metabolism  affecting  young 
children,  showing  itself  by  erroneous  bony  development  and 
general  malnutrition  and  produced  by  a  faulty  food  supply 
and  defective  hygiene.  / 

Etiology.  Both  sexes  are  affected  equally.  Symptoms 
usually  manifest  themselves  between  the  ages  of  six  months 
and  two  years.  Late  rickets  has  been  described  in  which 
the  onset  is  delayed  until  the  ninth  year  ;  such  cases  must 
be  very  rare. 

The  great  majority  of  cases  occur  in  infants  that  have 
been  fed  on  artificial  foods,  though  very  prolonged  breast 
feeding  is  said  to  favour  the  development  of  rickets. 

The  foods  which  are  most  frequently  responsible  for  rickets 
are  those  in  which  there  is  a  deficiency  in  both  fat  and  proteid 
and  consequently  an  excess  of  carbohydrate. 

There  is  in  addition  an  imperfect  assimilation  of  lime  salts. 

(i.)  The  general  symptoms  are  malaise  and  malnutrition  ; 
the  child  is  restless  and  tender  to  the  touch  ;  it  often  screams 
when  handled  ;  it  sweats  at  night,  especially  about  the  head, 
and  kicks  the  bedclothes  off.  The  complexion  becomes  dull 
and  earthy,  the  appetite  fails,  and  there  is  often  diarrhoea 
and  a  tendency  to  vomiting.  The  muscular  power  is  lost 
and  the  muscles  themselves  are  shrunken  and  flabby.  Con- 
vulsions are  not  uncommon,  and  there  is  a  notable  tendency 
to  reflex  spasms,  such  as  laryngismus  stridulus. 

(ii.)  The  Special  Signs  are  Bony  and  Visceral. 

M.D.  13 


194  MEDICAL  DIAGNOSIS 

(a)  Bony  Changes.  The  head  is  large  for  the  body ;  the 
fontanelle  remains  unduly  patent ;  bosses  form  in  the  parietal 
and  frontal  regions.  The  squamous  parts  of  the  cranial  bones 
may  be  thinned  Hke  parchment  (craniotabes). 

The  milk  teeth  erupt  late  and  are  prone  to  decay.  The 
thorax  shows  a  deep  groove  running  transversely  from  the 
lower  end  of  the  sternum  to  the  anterior  axillary  line 
(Harrison's  sulcus) — this  causes  the  xiphoid  and  lower  ribs 
to  appear  splayed  out  like  an  umbrella — while  the  sternum, 
as  a  whole,  becomes  depressed. 

The  ribs  present  a  characteristic  bony  knob  at  the  junction 
of  the  costal  cartilages  with  the  bony  ribs  (rickety 
rosary). 

The  spine  often  shows  a  curve  with  the  concavity  forwards. 

The  long  bones  show  curves  which  are  usually  exaggera- 
tions of  their  natural  curves. 

Both  knock-knee  and  bow-legs  are  common. 

The  epiphyses  of  the  long  bones  are  knobbly  and  thickened: 
this  is  particularly  evident  at  the  lower  end  of  the  femur 
and  at  the  wrist. 

The  pelvis  tends  to  fall  in  and  assume  a  tri -radiate  type. 

(6)  Visceral  Changes.  Bronchitis  is  both  common  and 
resistant  to  treatment  in  rickety  children. 

The  abdomen  is  protuberant  and  enlarged  ;  the  hver 
and  spleen  are  often  greatly  increased  in  size. 

The  blood  shows  an  anaemia  of  "  secondary  "  type. 

The  diagnosis  of  rickets  is  easy  in  advanced  cases  ;  the 
slighter  forms  may  well  be  overlooked. 

Congenital  syphilis  must  be  excluded,  if  necessary  by 
a  Wassermann  reaction  both  of  infant  and  mother,  though, 
of  course,  the  two  diseases  may  co-exist. 

Scurvy  may  be  suspected  where  tenderness  is  very  marked 
(vide  p.  168).  The  special  features  of  Achondroplasia  (p.  173) 
should  prevent  this  condition  being  mistaken  for  rickets. 

Paraplegia  of  cerebral  origin  has  sometimes  been  diagnosed 
in  cases  of  rickets  where  the  muscular  weakness  is  unusually 
pronounced  ;  but  even  if  the  rickety  child  cannot  stand 
he  can  stiU  kick  his  legs  about  freely  when  he  is  lying  on  his 
back — in  other  words,  there  is  no  paralysis. 


DISORDERS   OF   METABOLISM  195 

V.  ARTHRITIS  DEFORMANS. 

The  synonyms  for  and  varieties  of  this  condition  are  so 
numerous,  and  accurate  differentiation  between  them  is  so 
difficult,  that  considerable  confusion  may  result  in  the  mind 
of  anyone  studying  the  literature  of  the  subject. 

It  is  convenient,  clinicallj^  to  recognise  the  two  main 
groups — Rheumatoid  Arthritis  and  Osteo-arthritis — but  it 
must  be  clearly  understood  that  no  hard-and-fast  line 
can  be  drawn  between  them  and  that  often  both  conditions 
are  present  in  the  same  person. 

(a)  Rheumatoid  Arthritis.  This  disease  is  produced  by 
the  toxins  of  infective  bacteria,  or  possibly  sometimes  by 
the  micro-organisms  themselves.  There  is  always  a  focus 
somewhere  in  the  body  where  these  bacteria  are  settled 
and  whence  they  discharge  their  poisonous  products  into 
the  circulation  ;  sometimes,  indeed,  it  would  appear  that 
the  bacteria  themselves  enter  the  blood-stream.  Possible 
foci  of  this  nature  are — the  gums  and  tooth  sockets,  as  in 
pyorrhoea ;  the  accessory  sinuses  of  the  nose  ;  the  naso- 
pharynx ;  the  middle  ear ;  the  alimentary  canal,  and 
the  genito-urinary  tract. 

Although  the  condition  must  be  regarded  as  "  infective  " 
it  is  not  "  specific,"  since  similar  results  appear  to  be  obtained 
from  the  action  of  many  different  organisms,  to  most  of  which 
only  a  generic  name  (often  some  form  of  streptococcus) 
can  be  given  bacteriologically.  Rheumatoid  arthritis 
usually  starts  before  the  age  of  40,  often  in  the  third 
decade. 

The  characteristic  lesions  are  periarthritic  inflammations  ; 
the  fibrous  tissues  around  the  joints  are  the  structures 
principally  affected ;  the  essential  articular  elements  often 
escape,  but  may  be  involved  secondarily.  More  often  than 
not  there  is  no  effusion  into  the  joint,  but,  owing  to  the 
swelling  round  about  it,  the  joint  as  a  whole  looks  swollen 
and  puffy  and,  of  course,  movement  of  it  is  painful.  The 
spindle-shape  of  affected  joints  is  best  seen  in  chronic  cases 
where,  from  disuse,  wasting  of  the  muscles  above  and  below 
the  joint  has  supervened.  The  smaller  joints,  such  as  the 
fingers  and  wrists,  are  generally  attacked  first,  but  the  knees 

13—2 


196  MEDICAL  DIAGNOSIS 

and  elbows  are  often  involved  also  ;    the  hips,  shoulders, 
and  spine  more  often  escape. 

Once  started  the  disease  tends  to  be  progressive,  and  associ- 
ated trophic  changes  are  often  conspicuous,  such  as  glossy 
skin,  fibrillation  of  the  nails,  and  neuritis. 

The  disease  may  be  acute  in  onset,  and  at  first  hardly  to  be 
distinguished  from  acute  rheumatism  except  by  its  failure 
to  react  to  salicylates  ;  more  often  it  develops  insidiously, 
but  is  liable  to  subacute  exacerbations. 

(b)  Osteo-arthritis.  This  disease  partakes  more  of  the 
nature  of  a  degeneration  than  an  infection  ;  the  articular 
structures  themselves,  especially  the  cartilages  and  synovial 
membranes,  are  principally  affected.  There  may  be  much 
or  little  effusion.  Sometimes  there  seems  to  be  a  marked 
reactionary  and  perverted  overgrowth  of  the  affected  tissues, 
resulting  in  the  so-called  hypertrophic  form  with  lipping 
of  the  cartilages,  osteophytic  formation,  and  exuberance 
of  pulpy  synovial  membrane  ;  in  other  cases  the  process  is 
entirely  atrophic,  and  creaking  and  grating  in  the  affected 
joints  are  the  principal  features. 

A  Charcot's  joint  in  a  case  of  tabes  may  be  considered 
analogous  to  the  hypertrophic  form  of  osteo-arthritis 
except  for  its  painlessness  and  the  greatly  increased 
mobility,  which  contrasts  sharply  with  the  limitation  of 
movement,  or  even  fibrous  ankylosis,  of  osteo-arthritis. 

The  victims  of  osteo-arthritis  are  older  than  those  of 
rheumatoid  arthritis  ;  it  is  particularly  common  in  women 
about  the  menopause.  The  larger  joints  are  most  concerned, 
such  as  the  knees,  hips,  and  shoulders  ;  but  no  joint  is  im- 
mune, and  the  fingers,  spine,  and  temporo-mandibular 
articulation  are  frequently  affected. 

Trophic  changes,  as  in  rheumatoid  arthritis,  with  free 
perspiration  of  the  affected  parts,  may  be  expected.  Ulnar 
deviation  of  the  hand  is  not  uncommon,  and  can  be  distin- 
guished from  ulnar  paralysis  by  the  associated  joint  changes. 

Certain  special  varieties  of  arthritis  deformans  may  be 
mentioned  : — 

(i.)  StilVs  Disease.  This  seems  to  be  a  form  of  rheumatoid 
arthritis  occurring  in  children.  One  joint  (usually  a  knee)  is 
first  attacked ,  but  in  a  Uttle  time  one  or  several  more  become 


DISORDERS   or   METABOLISM  197 

involved.  At  the  same  time  the  lymphatic  glands  through- 
out the  body,  but  particularly  those  near  the  affected  joints, 
and  the  spleen  become  enlarged. 

This  train  of  signs  seems  to  point  to  an  infective  origin, 
since  the  glands  and  spleen  in  children  are  affected  by  lesser 
causes  than  are  necessary  to  produce  the  same  result  in 
adults. 

(ii.)  Acute  M on -articular  Osteo -arthritis.  A  variety  of 
osteo-arthritis  with  pain,  creaking,  and  grating,  occurring 
suddenly  in  old  people  and  strictly  limited  to  one  joint, 
nearly  always  a  shoulder  or  a  hip.  Trauma  is  often  respon- 
sible for  this  ty^e. 

(iii.)  Spondylitis  Deformans.  Osteo-arthritis  affecting  the 
spine  only.  The  spine  becomes  rigid  and  curved  forwards, 
so  that  the  patient's  chin  is  approximated  to  his  sternum, 
and  when  placed  on  his  back  his  occiput  is  many  inches  off 
the  bed.  Pain  in  this  form  is  often  severe  from  involvement 
of  nerve  roots,  and  there  is  commonly  an  associated  ascending 
degeneration  of  the  posterior  and  anterior  columns  of  the 
spinal  cord  with  muscular  atrophy  and  anaesthesia. 

(iv.)  Spondylose  Rhizomelique.  Osteo-arthritis  of  the 
spine,  hips,  and  shoulders.  In  this  variety  the  lesion  is 
usually  limited  to  one  region  of  the  spinal  column,  and  nervous 
symptoms  are  slight  or  absent. 

(v.)  Heberdens  nodes  are  bony  outgrowths  from  the  base 
of  the  distal  phalanges  of  the  fingers  ;  they  are  diagnostic 
of  osteo-arthritis,  and  are  significant  inasmuch  as  the  other 
manifestations  of  the  disease  are  likely  to  be  of  relative 
mildness. 

VI.  FIBROSITIS  (MUSCULAR  RHEUMATISM). 

Muscular  pains  of  varying  intensity  may  result  from  a 
toxic  inflammation  of  the  fibrous  tissues  between  various 
muscle  bundles.  The  tendency  for  these  pains  to  be  induced 
by  cold  and  damp  is  well  known. 

The  pathology  of  the  condition  is  obscure,  and  though 
rheumatism  is  often  blamed  it  is  doubtful  if  it  really  has  much 
to  do  with  it  except  possibly  in  cases  of  torticollis.  It 
seems  more  likely  that  in  many  cases  the  toxins  have  a 


198  MEDICAL   DIAGNOSIS 

similar  nature  and  origin  to  those  which  are  responsible 
for  rheumatoid  arthritis,  though  a  certain  proportion  of 
cases  appear  to  be  gouty. 

The  clinical  features  of  fibrositis  are  : — 

(i.)  Pain  in  certain  muscles,  especially  the  lumbar  muscles 
(lumbago),  the  intercostals  (pleurodynia),  the  neck  muscles 
(torticolhs),  and  the  shoulder  muscles  (omodynia). 

(ii.)  The  pain,  as  would  be  expected,  is  worse  on  movement 
of  the  affected  muscle,  but  also  is  often  increased  by  warmth, 
as  in  bed  ;  it  is  localised  to  the  affected  part  and  does  not 
radiate  like  the  pain  of  neuritis. 

(iii.)  Tender  points  can  often  be  made  out  in  the  affected 
muscles. 

(iv.)  A  characteristic  attitude,  varying  with  the  site  of  the 
lesion,  which  is  the  result  of  an  endeavour  to  avoid  the  use 
of  the  affected  muscles. 

(v.)  There  is  rarely  pyrexia  or  constitutional  disturbance. 

Lumbago  is  nearly  always  bilateral,  and  not  infrequently 
is  accompanied  by  sciatica  on  one  side.  There  is  extreme 
pain  on  attempting  to  resume  the  erect  posture  after 
stooping.  Lumbago  must  not  be  mistaken  for  stone  in 
the  kidney,  which  can  be  distinguished  by  the  characteristic 
referred  pains,  the  urinary  changes,  and,  if  necessary,  by 
the  X-rays. 

Pleurodynia  must  be  distinguished  from  pleurisy  by  the 
local  tenderness  and  the  absence  of  friction,  or  indeed  of 
any  pulmonary  abnormality,  if  the  patient  can  be  induced 
to  breathe  deeply. 

Omodynia  usually  has  definite  muscle  tenderness  and 
pain.  There  is  no  evidence  of  neuritis  {;vide  p.  505),  and  the 
shoulder-joint  can  be  shown  to  move  quite  freely  if  the 
affected  muscles  are  supported.  If  there  is  any  doubt  about 
the  shoulder- joint  the  X-rays  must  be  used. 

Fibrositis  can  be  distinguished  from  neuralgia  by  the 
periodic  nature  of  neuralgic  pain,  the  absence  of  stiffness, 
and  the  fact  that  movement  has  little  or  no  effect  on  it. 


CHAPTER  IV 

SUNSTROKE   AND   CERTAIN   INTOXICATIONS 

I.  SUNSTROKE  (INSOLATION). 

The  clinical  effects  of  insolation  may  result  from  the 
direct  exposure  to  the  rays  of  the  sun  or  from  exposure  to 
high  temperatures  in  the  shade.  A  considerable  proportion 
of  cases  first  manifest  symptoms  in  the  night.  An  impure 
atmosphere  with  moisture  is  more  apt  to  produce  sunstroke 
than  a  higher  temperature  with  a  pure,  dry  atmosphere. 
Sunstroke  is  most  common  when  the  thermometer  registers 
from  90°  to  110°  F,,  but  any  arbitrary  hmit  is  impossible. 

The  clinical  effects  of  high  atmospheric  temperaturefe  may 
be  considered  under  two  headings  : — 

(a)  Syncope  from  Exhaustion.  This  is  well  seen  in  soldiers 
on  the  march,  stokers  in  the  tropics,  etc. 

The  condition  is  essentially  one  of  syncope  ;  the  patient 
is  cold  and  pale  and  the  pulse  is  feeble  and  fluttering. 
Recovery  generally  ensues  in  a  few  hours  and  there  are  no 
evil  consequences.  Sometimes  high  fever  develops  (thermic 
fever)  when  the  patient  has  apparently  recovered  from  the 
syncope,  and  this  may  terminate  fatally  or  prove  so  intract- 
able as  to  necessitate  removal  to  a  colder  chmate.  More 
commonly  the  fever  gradually  subsides  and  a  good  recovery 
is  made,  though,  even  so,  a  change  of  cHmate  is  often 
advisable. 

(b)  Sunstroke  Proper  (Coup  de  Soleil).  This  usually 
results  from  the  effect  of  the  sun's  rays  on  the  back  of  the 
neck  and  head.  The  body  temperature  rises  to  106°  to  108° 
or  even  110°  F,  and  profound  asphyxial  symptoms  occur. 

Premonitory  symptoms,  such  as  restlessness,  headache, 
gasping  respiration,  nausea,  and  a  sense  of  dread  may  in 
cases  of  continued  exposure  to  a  high  temperature  precede 
the  actual  stroke  for  a  variable  period.  These  are  followed 
by  unconsciousness,  stertor,  lividity,  and  cyanosis.     On  the 


200  MEDICAL  DIAGNOSIS 

other  hand.,  the  "stroke"  may  occur  without  warning. 
Death  ensues  if  means  are  not  taken  to  lower  the  tem- 
perature in  from  twelve  to  forty-eight  hours. 

Relapses  are  not  infrequent,  and  persons  who  have  had 
sunstroke  of  this  type  are  often  particularly  intolerant  of 
even  moderate  heat  and  humidity  for  many  years  after- 
wards. Meningitis  occasionally  develops  in  the  course  of 
insolation,  and  a  goodly  number  of  those  who  recover  from 
a  severe  sunstroke  develop  later  signs  of  permanent  cerebral 
changes,  such  as  epilepsy,  loss  of  memory,  deafness,  blind- 
ness, paralysis,  dementia,  or  even  mania. 

II.  ALCOHOLISM. 

The  ordinary  manifestations  of  moderate  drunkenness  do 
not  need  description  here.     Alcoholism  will  be  considered 
under  three  headings  : — 
(i.)  Acute  Alcoholism, 
(ii.)  Chronic  Alcoholism, 
(iii.)  Delirium  Tremens. 
(i.)  Acute  Alcoholic  Poisoning.     The  result  of  an  overdose 
of  alcohol  may  produce  a  condition  of  stupor  or  uncon- 
sciousness  which   it   is   important   to    diagnose   correctly. 
There  may  be  a  history  of  recent  excess,  but  too  much  atten- 
tion should  not  be  paid  to  this,  for  the  temporary  rise  in 
blood  pressure  induced  by  alcohol  may  suffice  to  rupture  a 
cerebral  artery  ;    in  a  like  manner  the  smell  of  alcohol  in 
the  patient's  breath  is  of  some  value,  but  far  from  conclusive, 
since  the  administration  of  brandy  is  usually  the  first  step 
taken  by  the  laity  in  any  form  of  sudden  illness. 
The  following  points  may  prove  of  importance  : — 

(a)  The  breathing  is  slow  and  deep,  but  rarely  ster- 
torous. 

(6)  The  pupils  are  equal  and  dilated, 
(c)  The  unconsciousness  is  hardly  ever  so  deep  that  the 
patient   cannot  be   temporarily  roused  hj  shouting   or 
pinching  the  skin  of  the  neck. 

{(l)  There  is  no  evidence  of  paralysis. 
(e)  There  are  neither  convulsions  or  albuminuria. 
If  narcotic  poisoning  is  suspected,  or  indeed  in  any  case 


SUNSTROKE   AND   CERTAIN   INTOXICATIONS     20i 

where  the  presumptive  evidence  is  against  a  cerebral  lesion, 
it  is  advisable  to  wash  out  the  stomach.  The  obvious 
presence  of  large  quantities  of  alcohol  in  the  wash-out  is  a 
strong  point,  but  the  material  should  also  be  tested  for 
poisons,  since  morphia  or  chloral,  etc.,  may  have  been  taken 
while  under  the  influence  of  alcohol. 

In  all  cases  some  of  the  stomach  wash-out  should  be  kept 
till  the  diagnosis  is  absolutely  clear. 

The  speedy  return  to  consciousness  after  free  gastric 
lavage  is  striking  in  cases  of  simple  alcohol  poisoning. 

Some  unfortunate  persons  suffer  from  severe  toxic  gastro- 
intestinal disturbance  with  extreme  prostration  as  the  result 
of  alcohol  without  ever  showing  any  of  the  more  usual  signs 
of  inebriety.  In  such  cases  the  vomiting  sets  in  early,  but 
instead  of  ceasing  when  the  stomach  is  empty  it  continues  at 
very  frequent  intervals,  perhaps  for  thirty-six  to  forty-eight 
hours,  until  the  patient  is  seriously  collapsed  by  the  loss  of 
fluid  and  exhausted  from  the  repeated  strain.  ' 

The  differential  diagnosis  of  alcoholic  stupor,  from 
narcotic  poisoning,  uraemia,  and  cerebral  lesions  is  discussed 
on  p.  460. 

(ii.)  Chronic  Alcoholism.  The  effects  of  chronic  alcoholic 
excess  (even  though  the  subject  rarely  or  never  gets  drunk) 
are  generally  fairly  obvious  to  those  who  are  brought 
into  contact  with  him.  The  following  signs  may  be 
mentioned  : — 

(a)  General  Apj)earance.  Shifty  manner,  yellow  con- 
junctivse,  tremulous  lips,  red  nose,  acne  rosacea,  or 
rhinophyma. 

(6)  The  Digestive  System.  Flabby,  furred  tongue  ; 
nasty  taste  in  the  mouth  ;  chronic  gastritis  ;  morning 
vomiting  of  bile-stained  mucous  ;  no  appetite  for  break- 
fast ;  looseness  of  the  bowels  ;  piles,  and  even  positive 
evidence  of  cirrhosis  of  the  liver. 

(c)  Mental  SymiAoms.  The  mental  and  moral  qualities 
may  change  completely  :  the  patient  becomes  untruthful 
and  unmoral  ;  he  loses  his  memory  and  power  of  con- 
centration ;  he  may  be  exalted  with  grandiose  ideas,  or  he 
may  be  depressed  to  the  verge  of  melancholia.  He  is 
usually  suspicious  of  his  family  and  friends,  while  delusions 


202  MEDICAL  DIAGNOSIS 

either  transient  or  permanent  are  not  infrequent,   and 

may  be  so  extreme  as  to  necessitate  certification. 

{d)  Nervous    System.     Beyond    occasional    peripheral 

neuritis  {vide  p.  508),  there  is  usually  no  evidence  of  organic 

disease  ;   but  tremor  of  the  tongue,  lips,  and  extremities 

is  particularly  common. 

(e)  The  Kidneys.     Chronic  interstitial  nephritis  is  often 

the  result  of  chronic  alcoholism. 

(/)  The  Heart  commonly  shows  fibro -fatty  change. 

(iii.)  Delirium  Tremens  is  only  seen  in  the  chronic  alcohoHc  ; 
in  such  it  may  follow  on  some  extra  indulgence,  on  any 
intercurrent  accident  {e.g.,  broken  leg)  or  acute  illness  {e.g., 
pneumonia),  on  any  profound  mental  shock,  or  on  the  abrupt 
withdrawal  of  all  forms  of  alcohol. 

The  first  sign  is  tremor,  with  restlessness,  mental  depres- 
sion, and  insomnia.  In  about  twenty -four  hours  there  is 
noisy  delirium  ;  the  expression  is  anxious,  the  eyes  are 
bright  and  glistening,  and  in  a  short  while  definite  hallucina- 
tions appear.  The  patient  often  imagines  he  is  in  danger  of 
being  done  to  death  and  sees  curious  and  imaginary  animals 
about  the  room  or  crawling  on  the  bed.  He  naturally 
becomes  extremely  violent,  and  restraint  is  frequently 
necessary.  The  question  of  restraint  is  important  ;  it  should 
never  be  employed  unless  absolutely  necessary,  and  it  is  very 
striking  how  often  it  is  possible  to  keep  a  patient  compara- 
tively quiet  for  a  long  time  by  sitting  with  him  and  talking 
to  him  and  even  attempting  to  reason  with  him. 

The  exhaustion  produced  by  struggling  against  forcible 
restraint  often  proves  fatal,  especially  in  the  cases  following 
illness  or  accident. 

An  interesting  feature  of  many  cases  of  delirium  tremens 
is  the  tendency  for  the  hallucinations  to  be  closely  connected 
with  the  daily  life  of  the  individual — for  example,  a  bus- 
driver  will  imagine  himself  to  be  driving  his  bus  along  its 
accustomed  route,  and  if  he  is  given  a  pair  of  reins  tied  on 
to  the  end  of  his  bed  will  often  drive  away  contentedly  for 
hours. 

An  ordinary  case  of  delirium  tremens  wears  itself  out  in 
about  three  nights.  A  high  temperature  is  a  bad  sign. 
There  is  a  great  tendency  for  pulmonary  affections,  such  as 


SUNSTROKE   AND   CERTAIN  INTOXICATIONS     203 

tuberculosis  or  broncho-pneumonia,  to  develop  in  those  who 
are  chronic  alcoholics.  Apical  pneumonia  is  peculiarly  liable 
to  be  associated  with  delirium  tremens.  In  aU  cases  the 
lungs  should  be  carefully  and  repeatedly  examined. 

The  differential  diagnosis  of  Chronic  Alcoholism  from 
General  Paralysis  is  indicated  on  p.  550. 

III.    MORPHINISM. 

Enormous  quantities  of  opium  or  its  alkaloid  morphia 
may  be  taken  by  those  addicted  to  the  habit.  Over  300 
grains  a  day  were  taken  by  De  Quincey. 

A  morphinist  appears  older  than  his  years  :  his  complexion 
has  a  pale,  dull,  earthy  look  ;  his  eyes  are  sunk  (the  pupils 
may  be  smal],  but  this  depends  rather  upon  how  recently  a 
dose  has  been  taken;  in  the  intervals  they  are  often  dilated) ; 
his  expression  vacant  or  dreamy,  and  his  body  emaciated. 
When  not  under  the  influence  of  the  drug  the  patiept  is 
depressed,  irritable,  and  restless  ;  he  has  a  great  sense  of 
mental  and  bodily  weariness,  and  as  the  time  for  a  dose  draws 
near  he  has  acute  abdominal  pain,  nausea,  and  vomiting. 
The  effect  of  a  sufficient  dose  is  marvellous  ;  there  is  an 
almost  instantaneous  recovery  of  mental  and  physical  powers 
while  the  patient  looks  years  younger  for  the  time  being. 

One  of  the  most  significant  features  of  the  morphia  habit 
is  the  effect  on  the  moral  qualities  of  the  victim  ;  he  is 
always  untrutliful  and  furtive,  especially  so  in  relation  to 
his  vice,  but  often  in  all  other  matters  as  weU.  It  is  no  uncom  - 
mon  thing  for  a  patient  voluntarily  to  present  himself  for 
treatment  in  a  nursing  home  with  large  quantities  of  the 
drug  secreted  about  his  person. 

Itching  of  the  dry  skin  is  common,  and  this  causes 
repeated  rubbing  of  the  nose,  which  has  been  emphasised 
by  some  writers  as  a  diagnostic  feature. 

The  diagnosis  of  morphinism  is  not  difficult  provided 
sufficient  observation  of  the  patient  can  be  employed. 

The  appearance,  the  mental  character,  and  the  alterna- 
tions of  vigour  and  apath}'^  are  sufficiently  striking. 

Confirmation  may  be  afforded  by  the  discovery  of 
numerous  puncture  marks,  especially  on  the  left  forearm 
or  right  thigh. 


204  MEDICAL  DIAGNOSIS 

The  cocaine  habit  presents  a  very  similar  clinical  syn- 
drome to  that  described  under  "  Morphinism."  Itching 
is  an  even  more  constant  feature.  The  pupils  may  be 
widely  dilated,  and  certainly  are  not  contracted. 

IV.     LEAD  POISONING  (PLUMBISM). 

Lead  poisoning  may  be  acquired  by  contamination  of  the 
water  supply,  in  the  course  of  various  industrial  occupations, 
such  as  painting,  plumbing,  type-setting,  etc.,  or  wilfully  (as 
by  eating  diachylon  plaster)  to  produce  abortion. 

The  following  are  the  principal  features  of  plumbism  : — 

(i.)  Ancemia  and  Cachexia.  There  is  a  severe  ansemia,  of 
which  the  features  are  : 

(a)  Great  diminution  in  red  cells. 

(6)  Corresponding  decrease  in  haemoglobin,  so  that  the 

colour  index  is  not  low. 

(c)  Basophile  stippling  of  the  red  cells. 
{d)  Poikilocytosis. 

There  is  no  leucopenia,  and  the  blood  does  not  show 
megaloblasts  so  constantly  as  in  pernicious  anaemia.  A 
certain  number  of  normoblasts  are  nearly  always  to  be  found. 

(ii.)  Blue  Line  on  the  Gums.  This  is  a  punctate  or  inter- 
mittent line  on  the  edge  of  the  gums,  best  marked  on  the 
papillae  between  the  teeth.  It  does  not  appear  readily 
in  persons  who  have  scrupulously  clean  mouths,  and  on  the 
other  hand  must  not  be  confounded  with  the  continuous 
dirty,  grey-blue  hne  of  those  who  have  advanced  pyorrhoea 
alveolaris. 

(iii.)  Colic  and  Constipation.  A  true  colicky  pain,  often 
extremely  severe,  of  maximum  intensity  at  the  umbilicus, 
but  often  to  be  traced  along  the  course  of  the  colon.  Consti- 
pation is  generally  intractable. 

(iv.)  Encephalopathy.  This  may  vary  from  simple  head- 
ache to  convulsions,  delirium,  and  even  coma. 

Optic  neuritis  may  be  present.  Delusional  insanity  has 
been  recorded. 

(v.)  Gout  and  granular  kidney  are  particularly  frequent 
in  those  who  suffer  from  plumbism. 

(vi.)  Miscarriages  are  the  rule  in  lead  poisoning. 


SUNSTROKE   AND   CERTAIN  INTOXICATIONS     205 

(vii.)  Neuritis  {vide  p.  509). 

The  diagnosis  of  lead  poisoning  rests  on  a  judicious 
analysis  of  such  of  the  preceding  signs  as  may  be  present 
in  any  case.  The  history  is  very  important  except  in  cases 
in  which  lead  has  been  taken  to  procure  abortion. 

The  differential  diagnosis  of  such  individual  signs  as 
neuritis,  colic,  etc.,  is  dealt  with  elsewhere  under  these 
headings.  In  cases  of  doubt,  lead  should  be  looked  for 
in  the  urine,  though  the  discovery  of  lead  is  not  proof 
positive  of  lead-poisoning. 

V.     CHRONIC  ARSENICAL  POISONING. 

This  may  be  acquired  by  workers  in  certain  trades,  such 
as  wall-paper  makers,  workers  in  artificial  flowers,  etc.,  but 
the  Board  of  Trade  Regulations  have  largely  minimised 
these  risks.  It  may  also  be  acquired  by  the  contamination 
of  food  supplies,  as  in  the  recent  outbreak  at  Manchester 
due  to  contaminated  beer,  by  overdosage  in  medicine  and, 
lastly,  it  may  be  administered  with  homicidal  intent. 

The  Symptoms  are  : — 

(i.)  Gastro-intcstinal  disturbances,  such  as  colicky  pains, 
nausea,  vomiting,  and  diarrhoea. 

(ii.)  Flushing  of  the  skin,  with  puffiness  of  the  eyes. 

(iii.)  Conjunctivitis  and  catarrh  of  the  respiratory  tract. 

(iv.)  Numbness  and  tingling  of  the  extremities  and 
neuritis  [vide  p.  509), 

(v.)  Pigmentation  and  thickening  of  the  skin  (keratosis), 
especially  of  the  palms  of  the  hands  and  the  soles  of 
the  feet. 

(vi.)  Epithelioma  has  been  described  as  a  late  development 
of  the  keratosis. 

The  diagnosis  of  chronic  arsenical  poisoning  depends  on 
the  signs  enumerated  above  and  a  history  of  exposure  to 
•the  influence  of  the  poison. 

The  danger  of  exposing  patients  with  such  chronic 
diseases  as  lymphadenoma  or  pernicious  anaimia  to  the  risk 
of  arsenical  poisoning  in  the  course  of  treatment  should 
always  be  borne  in  mind. 

Acute   arsenical   poisoning   gives   the  signs  of    an  acute 


206  MEDICAL  DIAGNOSIS 

irritant  poison  ;  abdominal  pain,  vomiting,  diarrhoea,  tenes- 
mus, and  collapse  ;  in  addition  there  are  muscle  cramps  and 
sometimes  convulsions  or  paralysis. 

VI.    CHRONIC  MERCURIAL   POISONING. 

This  occurs  in  those  who  work  in  mercury  or  in  mercury 
mines. 

The  outstanding  sign  is  a  rather  coarse  tremor,  at  first 
volitional,  later  constant,  but  always  increased  by  "inten- 
tion." The  tremor  starts  in  the  face  and  tongue,  and  then 
spreads  to  the  upper  limbs  and  finally  to  the  legs.  It  may 
be  so  severe  as  to  prevent  speech  or  walking. 

A  history  of  exposure  to  mercury  vapour  can  always 
be  obtained  ;  apart  from  this  the  diagnosis  must  be  made 
from  paralysis  agitans  and  disseminated  sclerosis. 

In  paralysis  agitans  the  tremor  can,  at  first,  be  con- 
trolled by  will  power,  and  continues  when  the  patient  is 
at  rest.  The  tongue  is  not  often  affected,  and  certainly 
not  in  the  early  stages.  The  characteristic  rigidity  of 
paralysis  agitans  is  not  met  with  in  mercurialism  {vide 
also  p.  570). 

In  disseminated  sclerosis  there  is  nystagmus  and  some 
evidence  of  an  upper  motor  neuron  lesion  {vide  p.  552). 


PART  III 

CHAPTER     I 

DISEASES    OF    THE    CARDIO-VASf'ULAR   SYSTEM   AND 
PERICARDIUM 

I.    THE  NORMAL  HEART. 

The  boundaries  of  the  heart  as  outhned  on  the  front  of 
the  chest  in  a  healthy  individual  may  be  represented  by  the 
following  four  lines  : — 

The  upper  border  is  formed  by  a  line  joining  the  two 
second  costal  cartilages  and  extending  about  1  inch  to  either 
side  of  the  sternum.  The  right  border  reaches  from  the  right 
extremity  of  the  upper  or  base  line  to  the  chondro-sternal 
junction  of  the  sixth  rib  on  the  right  side.  This  border  is 
slightly  convex  towards  the  right,  the  greatest  convexity 
being  reached  at  the  level  of  the  fourth  rib,  at  which  spot 
the  right  limit  of  the  heart  is  about  1 J  inches  from  the  middle 
line.  The  lower  border  of  the  heart  is  represented  by  a  line 
joining  the  sixth  right  chondro-sternal  junction  with  the 
apex  beat.  This  border  merges  with  the  liver  dulness  and 
is  scarcely  to  be  distinguished  by  percussion.  The  left 
border  runs  from  the  left  extremity  of  the  base  line  to  the 
apex  beat  ;  it  is  definitely  curved  with  its  convexity  out- 
wards. The  apex  beat  is  situated  in  the  fifth  left  space 
I  inch  internal  to  the  mid-clavicular  line  and  about  3|  inches 
from  the  mid-sternal  line.  The  area  thus  mapped  out  is 
known  as  the  deep  cardiac  dulness.  It  consists  almost 
entirely  of  right  ventricle  and  right  auricle  except  for  a 
narrow  strip  of  the  left  ventricle  towards  the  left  and  the 
left  auricular  appendix,  which  is  situated  behind  the  inner 
portion  of  the  third  left  chondral  cartilage. 

The  greater  proportion  of  the  heart  is  separated  from  the 
chest  wall  by  the  lungs  ;  that  part  which  lies  directly 
beneath  the  thoracic   parietes   corresponds  to  the  area  of 


208  MEDICAL  DIAGNOSIS 

superficial  cardiac  dulness.  This  is  a  small  area  the  right 
border  of  which  is  the  mid-line  of  the  sternum,  whilst  the 
upper  limit  is  usually  about  the  level  of  the  upper  border 
of  the  fourth  rib  and  the  left  border  follows  a  hne  convexly 
from  the  fourth  chondro-sternal  junction  to  the  apex. 

The  sounds  of  the  heart  are  two  in  number  :  the  first 
sound  is  formed  partly  by  the  muscle  sound  of  the  contracting 
ventricles  and  partly  by  the  tension  of  the  auricular-ven- 
tricular valves  ;  the  second  sound  is  produced  entirely  by 
the  closure-tension  of  the  aortic  and  pulmonary  valves. 
The  first  sound  is  best  heard  at  the  apex  ;  the  second  sound 
at  the  base. 

In  children  the  pulmonary  second  sound  is  louder  than 
the  aortic  second  sound  ;  in  adults  the  converse  usually 
obtains. 

Cardiac  systole  extends  from  the  commencement  of  the 
first  sound  to  the  commencement  of  the  second  sound, 
diastole  from  the  commencement  of  the  second  sound  to 
the  commencement  of  the  first.  The  systolic  interval  is 
shorter  than  the  diastolic,  the  first  sound  is  of  longer  duration 
and  of  less  tension  than  the  second. 

The  four  cardiac  valves  are  grouped  together  within  a 
very  small  area  ;  it  is  therefore  convenient  to  listen  at 
places  to  which  the  individual  valve  sounds  are  best  con- 
ducted, when  it  is  desirable  to  investigate  the  sound  generated 
at  a  particular  valve.  These  auscultation  areas  are  known 
by  the  names  of  the  valves  whose  sounds  are  conducted 
thither.  Thus,  aortic  valve  sounds  are  best  heard  at  the 
aortic  area,  which  is  the  second  right  costal  cartilage ;  the 
pulmonary  valve  sounds  at  the  inner  end  of  the  third  left 
space  ;  the  mitral  valve  sounds  at  the  apex,  and  the  tri- 
cuspid valve  sounds  in  the  fifth  or  sixth  left  space  close  to 
the  sternum. 

The  cardiac  impulse  can  be  seen  or  felt  in  the  majority 
of  healthy  people  as  a  circumscribed  systolic  thrust  in  the 
neighbourhood  of  the  heart's  apex,  but  it  should  not  occupy 
a  greater  area  than  one  square  inch.  The  cardiac  impulse 
does  not  really  correspond  to  the  anatomical  apex  of  the 
heart,  but  to  a  spot  situated  at  or  about  the  junction  of 
the  middle  and  lower  thirds  of  the  left  ventricle. 


l-'ic;  40.  DiiiL'rain  t<>  :^h(j\v  the  ic'atinn  "f  th;- 
Heart  and  (Ireat  Wsscls  t.)  the  ('l)fst  Wall 
and  to  the  Luntrs  The  dotted  red  lines 
indicate  the  surface  niari<iiiLr  of  the  Limy.- 
and  their  intci-lol)ar  septa. 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  209 


II.  THE  SIGNIFICANCE  OF  DISPLACEMENT 
OF  THE  APEX  BEAT  AND  ALTERATION 
IN  THE  CHARACTER  OF  THE  CARDIAC 
IMPULSE. 

In  children  the  heart  is  relatively  wider  laterally  than  in 
adults,  hence  the  apex  beat  is  found  in  the  fourth  space 
instead  of  the  fifth  and  often  slightly  external  to  the  mid- 
clavicular line.  Where  there  is  marked  emphysema,  or 
where  there  is  much  fat  or  thick  musculature,  it  may  be 
impossible  to  locate  the  apex  beat,  a  condition  which  may 
also  be  produced  by  a  verj'  feeble  heart,  oedema  of  the  chest 
wall,  and  sometimes  by  pericardial  effusion.  The  position 
of  the  apex  may  be  modified  by  various  intra-thoracic  con- 
ditions without  there  being  any  cardiac  lesion.  A  pleural 
effusion  or  pneumo-thorax  will  displace  the  heart  towards 
the  sound  side,  and  a  pulmonary  neoplasm  may  havef  the 
same  effect. 

Fibrosis  of  a  lung  wiU  pull  the  heart  towards  the  affected 
side,  and  if  the  fibrosis  is  principally  in  the  left  upper  lobe 
the  apex  may  be  di'awn  up  into  the  fourth  space.  Various 
intra-abdominal  conditions,  such  as  subphrenic  abscess, 
ascites,  etc.,  may  push  up  the  diaphragm  and  so  displace 
the  heart  upwards. 

Hypertrophy  of  the  left  ventricle  will  displace  the  apex 
downwards  and  slightly  outwards  ;  hypertrophy  of  the  right 
ventricle  does  not  tend  to  produce  much  alteration  of  the 
position  of  the  apex,  since  the  effect  is  rather  to  rotate  the 
heart  on  its  own  axis,  thus  pushing  the  left  ventricle  away 
from  the  chest  wall  and  causing  the  cardiac  impulse  to  be 
formed  by  the  right  ventricle  internal  to  the  mid-clavicular 
line.  Where  there  is  very  great  hypertrophy  of  the  right 
ventricle  the  apex  may  be  displaced  considerably  to  the  left, 
and  a  heaving  impulse  is  also  present  below  the  costal  margin. 
Hypertropliy  of  both  ventricles  displaces  the  apex  downwards 
and  outwards. 

Both  cardiac  hypertrophy  and  dilatation  produce  an 
increase  in  the  area  of  the  cardiac  impulse  ;  but  in  the  former 
case  the  tlirust  is  heaving  and  powerful,  whereas  in  the  latter 

M.D.  14 


210  MEDICAL  DIAGNOSIS 

it  is  weak,  indeterminate,  and  diffuse.  An  extensive  heaving 
impulse,  easily  felt  below  the  costal  margin,  is  the  rule  in 
mitral  reflux  :  a  short,  sharp  slappy  impulse  is  one  of  the 
most  important  signs  of  mitral  stenosis. 

Adherent  pericardium  gives  rise  to  a  diffuse  wavy  impulse, 
and  often  to  systolic  retraction  of  the  intercostal  spaces  m 
addition.  Pericardial  effusion  may  occasionally  push  the 
impulse  up  into  the  fourth  space. 

Pulsations  not  caused  by  the  Apex  Beat.  Pulsation  in  the 
neighbourhood  of  the  manubrium  is  suggestive  of  aortic 
aneurysm  ;  it  may  also  soiuttimes  be  met  with  in  cases  of 
mediastinal  new  growth  or  empyemia.  Pulsation  in  the 
third  and  fourth  left  spaces  may  be  found  in  healthy  people 
after  violent  exercise  or  in  the  forcibly  acting  hearts  of 
nervous  people  ;  more  generally,  however,  it  is  met  with  in 
cardiac  dilatation,  fibrosis  of  the  left  lung,  or  severe  anaemia. 


III.  THE  SIGNIFICANCE  OF  ALTERATIONS  IN 
CARDIAC    DULNESS. 

The  superficial  cardiac  dulness  may  be  increased  by  the 
enlargement  of  the  heart,  either  from  hypertrophy  or  dila- 
tation, which  pushes  aside  the  lung  fringes,  by  retraction 
of  the  lung  from  collapse  or  fibrosis,  and  by  pericardial 
effusion. 

Theoretically  more  valuable  information,  will  be  gained  by 
mapping  out  the  area  of  deep  than  of  superficial  cardiac 
dulness,  and  if  it  could  ahvays  be  accurately  delimited  this 
would  be  true  practically.  Unfortunately,  however,  the 
deep  dulness  cannot  always  be  made  out.  In  such  cases  we 
may  be  compelled  to  rely  on  the  superficial  area. 

The  borders  of  the  heart  should  be  investigated  from  two 
points  of  view — first,  abnormalities  in  position,  and,  secondly 
abnormalities  in  shape. 

Enlargement  of  the  left  ventricle  displaces  the  left  border 
of  the  heart  outwards  to  a  variable  extent,  but  it  also 
causes  it  to  be  continued  downwards  even  to  the  seventh 
space. 

Enlargement  of  the  right  ventricle  increases  the  area  of 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  211 

deep  cardiac  dulness  a  variable  distance  to  the  right  of  the 
sternum,  and  also  produces  a  powerful  heaving  impulse 
below  the  xiphoid  and  left  costal  margin.  The  right  border, 
which  is  form3d  by  the  right  auricle,  may  assume  a  greater 
convexity  from  enlargement  of  this  chamber.  At  the  same 
time  the  left  border  of  the  heart  may  be  displaced  outwards, 
but  will  usually  maintain  its  ordinary  shape.  Enlargement 
of  both  ventricles  will  produce  a  combination  of  these 
features. 

Enlargement  of  the  left  auricle,  as  seen  in  some  cases  of 
mitral  disease,  will  produce  an  increase  upwards  of  the  cardiac 
dulness  to  the  left  of  the  sternum  ;  the  line  msiy  have  a 
marked  convexity  upwards  and  to  the  left. 

Enlargement  of  the  right  auricle  will  affect  the  right  border 
of  the  heart  and  will  not  be  met  with  apart  from  enlargement 
of  the  right  ventricle,  except  possibly  in  those  rare  cases 
when  tricuspid  stenosis  is  the  most  prominent  valvular 
lesion.  ' 

An  increase  of  dulness  to  the  right  of  the  sternum  in  the 
first  and  second  spaces  is  suggestive  of  aortic  aneurysm  or  of 
dilatation  of  the  ascending  aorta. 

A  triangular  area  of  dulness  with  the  base  downwards,  and 
particularly  with  the  right  border  showing  7io  convexity,  is 
suggestive  of  pericardial  effusion. 

A  very  marked  increase  in  the  area  of  deep  cardiac  dulness 
is  caused  by  adherent  pericardium. 

In  percussing  out  the  areas  of  cardiac  dulness  it  is 
well  to  remember  that  the  finger  should  be  placed  firmly 
on  the  chest  wall  and  parallel  to  the  assumed  direction 
of  the  line  that  is  being  investigated  and  that  percussion 
should  be  light  yet  firm,  should  be  performed  with  a 
free  wrist  and  should  not  be  performed  alternately  on  rib 
and  interspace. 

Prsecordial  bulging,  apart  from  bonj'  deformities,  such  as 
rickets  or  spinal  caries,  is  commonly  due  to  aortic  aneurysm 
or  to  new  growth.  It  may  be  caused  by  extreme  cardiac 
enlargement,  especially  if  such  date  from  childhood.  Lastly, 
it  may  occur  in  large  pericardial  effusions,  particularly  in 
young  patients. 

14—2 


212  MEDICAL  DIAGNOSIS 


IV.     SIGNIFICANCE   OF    ALTERATION    IN   THE 
CARDIAC   SOUNDS  AND  THEIR  SPACING. 

In  health  the  cardiac  rhythm  should  be  regular,  even 
though  the  rate  is  greatly  accelerated  by  violent  exercise. 
In  young  children,  however,  the  rhythm  is  often  habitually 
irregular,  but  this  does  not  necessarily  indicate  any  patho- 
logical condition  {vide  p.  240). 

Since  the  first  sound  is  partly  generated  in  the  ventricular 
muscles,  undue  prominence  of  it  must  mean  an  increase  in 
the  activity  of  one  or  other  ventriclej  and  betokens  hyper- 
trophy from  one  or  another  cause. 

The  first  sound  in  hypertrophy  may  be  described  as  low- 
pitched  and  muffled.  When,  however,  the  hypertrophied 
ventricle  is  beginning  to  be  unequal  to  the  strain  imposed 
upon  it,  the  first  sound  at  first  becomes  rather  indistinct,  and 
when  there  is  distinct  dilatation  the  muscle-sound  appears 
to  be  lost  and  the  first  sound  becomes  short  and  sharp  like  an 
ordinary  second  sound. 

The  short,  sharp  first  sound  of  mitral  stenosis  is  not  due 
to  ventricular  dilatation,  but  to  the  forcible  contraction  of 
the  left  ventricle  before  it  is  completely  filled. 

A  reduplication  of  the  first  sound  is  taken  to  mean 
asynchronism  of  the  two  ventricles,  with  the  result  that  the 
tricuspid  and  mitral  valves  do  not  become  tense  at  the  same 
time. 

Intermission  of  the  first  sound  every  few  beats  may  occur 
as  a  constant  feature  in  certain  perfectly  healthy  hearts  ; 
it  is,  however,  sometimes  of  serious  significance  where  there 
is  cardiac  fibrosis  {vide  p.  246). 

Accentuation  of  the  second  sound  indicates  high  pressure 
in  the  systemic  or  pulmonary  arteries  respectively — e.g., 
the  ringing  aortic  second  sound  of  chronic  interstitial 
nephritis  and  the  accentuated  pulmonary  second  sound 
of  mitral  stenosis.  So  long  as  the  second  sound  is  thus 
accentuated  the  ventricles  are  capable  of  performing  the 
work  required  of  them.  When  one  of  the  ventricles  begins 
to  be  unequal  to  its  task,  or  when  from  force  of  circum- 
stances one  ventricle  is  acting  relatively  much  more  power- 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM  213 

fulh^  than  the  other,  the  second  sound  at  the  base  is  hkely 
to  become  redupHcated,  and  in  severe  dilatation  the  second 
sound  gets  shorter  and  weaker  until  in  some  cases  it  may  be 
inaudible. 

Apparent  reduplication  of  the  apical  second  sound 
when  there  is  no  reduphcation  at  the  base  is  a  common 
feature  in  mitral  stenosis,  and  is  in  reality  a  mid- 
diastoUc  murmur  which  simulates  a  doubling  of  the  second 
sound. 

The  spacing  of  the  heart  sounds  may  be  altered  in  two 
ways.  Systole  may  be  prolonged  at  the  expense  of  diastole 
till  both  are  of  equal  length.  This  "  tic-tac  "  rhythm,  as  it 
is  called,  suggests  a  heart  which  is  no  longer  capable  of 
dealing  with  some  increased  strain  which  it  has  been  called 
upon  to  face.  It  is  met  with  in  cases  of  arterio-sclerosis 
when  the  limit  of  hypertrophy  has  been  reached.  In  other 
cases  both  systole  and  diastole  may  be  greatly  shortened, 
causing  the  sounds  to  appear  unduly  close  together  {bruit 
de  galop) ;  this  condition  is  significant  of  grave  myocardial 
asthenia. 


V.  THE  SIGNIFICANCE  OF  CARDIAC  MURMURS 
AND    THRILLS. 

A.  Murmurs.  A  murmur  may  be  defined  as  an  endocardial 
sound  generated  at  one  of  the  cardiac  valves  and  produced 
by  an  abnormal  relationship  between  that  valve  and  its 
neighbouring  structures,  or  at  some  undue  constriction  in 
the  tubular  arrangement  of  the  cardio- vascular  system 
resulting  from  some  congenital  defect  in  the  development 
of  the  heart  and  vessels.  In  the  majority  of  cases  a  thrill 
is  a  palpable  murmur. 

For  the  purpose  of  diagnosis  murmurs  are  divided  into 
two  main  groups — {a)  Functional,  and  (6)  Organic. 

(a)  Functional  Murmurs  are  met  with  in  conditions 
of  aiucmia  and  debility  ;  they  are  not  associated  with  any 
impairment  of  valvular  function  or  with  any  congenital 
defect.  They  are  always  systolic  in  time  and  originate  at 
lither  the  aortic  or  pulmonary  valves.     The  most  common 


214  MEDICAL  DIAGNOSIS 

hsemic  murmur  is  due  to  dilatation  of  the  conus  arteriosus, 
thus  causing  a  purely  relative  stenosis  of  the  puhnonary 
valve.  The  murmur  is  usually  soft,  but  may  be  distinctly 
vibratory  ;  its  point  of  maximum  intensity  is  at  the  inner 
end  of  the  third  left  space.  It  is  commonly  conducted  up 
towards  the  left  clavicle  across  to  the  aortic  area  and  down 
towards  the  apex.  Sometimes  it  is  limited  to  the  pulmonary 
and  aortic  bases,  and  sometimes  it  can  only  be  heard  just 
to  the  left  of  the  sternum  in  the  third,  fourth,  and  fifth 
spaces. 

More  rarely  a  hsemic  murmur  is  generated  at  the  aortic 
valve  ;  it  is  then  supposed  to  be  due  to  dilatation  of  the  upper 
part  of  the  left  ventricle  immediately  below  the  aortic 
ring,  thus  producing  a  purely  relative  stenosis  of  the  aortic 
valve.  The  point  of  maximum  intensity  of  this  murmur 
is  at  or  about  the  second  right 'costal  cartilage.  It  is  con- 
ducted across  to  the  pulmonary  area,  up  towards  the  right 
sterno-clavicular  articulation,  and  to  a  varying  extent  down 
towards  the  apex.  Hsemic  murmurs  are  most  distinct  when 
the  patient  is  lying  down  ;  they  may  sometimes  disappear 
completely  when  the  erect  position  is  assumed. 

It  is  customary  to  describe  as  functional  systolic  murmurs 
limited  to  the  mitral  or  tricuspid  areas  and  occurring  in 
people  who  are  suffering  from  toxic  conditions,  anaemia,  and 
the  like.  Such  murmurs  indicate  slight  dilatation  of  the 
mitral  and  tricuspid  rings  resulting  from  sesthenia  or  toxic 
myocarditis  ;  as  the  patient  recovers  so  do  the  murmurs 
disappear,  but  while  thej  last  they  indicate  a  true  though 
transient  inadequacy  of  the  auriculo-ventricular  valves. 

(6)  Organic  Murmurs  indicate  structural  deformity  of 
the  valve  concerned.  Each  valve  may  be  affected  in  two 
ways  ;  it  may  be  obstructed  or  it  may  be  incompetent  and 
so  permit  of  regurgitation  through  its  orifice.  In  many 
cases  both  incompetence  and  obstruction  are  present  at 
the  same  time. 

By  estimating  the  time  of  the  cardiac  cycle  occupied 
by  the  murmur  or  murmurs,  and  also  their  points  of  maxi- 
mum intensity  and  lines  of  conduction,  it  is  possible  to 
state  with  considerable  accuracy  what  valves  are  affected 
and  what  is  the  nature  of  their  lesions.     With  regard  to  the 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  215 

determination  of  the  extent  or  severity  of  the  particular 
lesions,  murmurs  by  themselves  are  of  little  value  ;  the 
loudest  murmurs  may  be  produced  by  the  slightest  lesions. 

The  following  list  will  indicate  the  particular  murmurs 
associated  with  the  different  forms  of  valvular  disease  : — 

(i.)  Aortic  Reflux,  (a)  A  diastolic  murmur,  usually  soft 
and  blowing,  accompanying  or  replacing  the  second  sound, 
and  best  heard  at  the  aortic  cartilage  or  over  the  middle 
of  the  sternum  between  the  second  cartilages,  or  sometimes 
in  the  pulmonary  area  or  down  the  left  border  of  the  sternum. 
The  lines  of  conduction  are  across  to  the  pulmonary  base 
down  both  sides  of  the  sternum  and  fo  the  apex.  (6)  A  pre- 
systolic aortic  murmur  is  often  heard  at  the  mitral  area 
(Flint's  murmur).  This  is  due  to  the  impinging  of  the 
refluent  blood-stream  through  the  aortic  valve  on  to  the 
anterior  curtain  of  the  mitral  valve,  thus  producing  a  slight 
obstruction  at  the  mitral  valve,  (c)  A  systolic  murmur 
accompanying  the  first  sound  and  of  maximum  intensity  at 
the  aortic  area  is  very  frequently  heard  in  cases  of  aortic 
reflux.  It  exactly  resembles  the  murmur  of  aortic  stenosis, 
but  in  the  majority  of  cases  is  due  to  thickening  or  roughen- 
ing of  the  aortic  cusps  and  not  to  true  stenosis. 

(ii.)  Aortic  Stenosis.  A  systolic  murmur  best  heard  at 
the  aortic  area  and  conducted  up  into  the  vessels  of  the  neck. 
It  is  often  to  be  heard  behind  between  the  left  scapula  and 
the  mid-line.  This  murmur  accompanies  or  replaces  the 
first  sound  and  is  usually  rough  and  vibratory.  It  must 
be  remembered  that  an  aortic  systolic  murmur  is  a  very 
common  murmur,  but  that  aortic  stenosis  is  a  rare  condition. 
This  apparent  anomaly  is  accounted  for  by  the  fact  that 
dilatation  of  the  first  part  of  the  aorta  and  slight  atheroma 
of  the  aortic  valves  are  both  common  conditions  and  will 
l)()th  ])roduce  a  systolic  murmur. 

(iii.)  Mitral  Reflux.  A  soft  blowing  systolic  murmur 
best  heard  at  the  mitral  area,  conducted  out  into  the  axilla, 
and  often  also  audible  between  the  angk;  of  the  scapula  and 
the  vertebral  groove  behind. 

(iv.)  Mitral  Stenosis,  {a)  A  rough  presystolic  murmur 
lunning  up  to  the  first  sound,  best  heard  just  internal  to 
the  apex  and  localised  to  this  neighbourhood.    (6)  A  murmur 


216  MEDICAL  DIAGNOSIS 

occupying  the  whole  or  any  part  of  diastole,  but  most 
frequently  a  short  mid-diastolic  murmur,  (c)  A  systolic 
mitral  murmur,  poorly  conducted  and  not  heard  behind 
(Graham  Steel's  murmur). 

(v.)  Pulmonary  Reflux.  A  diastohc  murmur  of  maxi- 
mum intensity  at  the  pulmonary  area  and  conducted  down 
the  edges  of  the  sternum.     This  lesion  is  extremely  rare. 

(vi.)  Pulmonary  Stenosis.  A  rough  systolic  murmur 
best  heard  at  the  pulmonary  area  and  conducted  up  towards 
the  left  clavicle.  This  lesion  is  extremely  rare  except  as  a 
congenital  deformity. 

(vii.)  Tricuspid  Reflux.  A  soft  systolic  murmur,  often 
inaudible,  best  heard  at  the  tricuspid  area  and  conducted 
out  for  a  short  distance  only  towards  the  apex. 

(viii.)  Tricuspid  Stenosis.  A  presystolic  murmur  local- 
ised to  the  tricuspid  area.  Tricuspid  stenosis  does  not  occur 
apart  from  mitral  stenosis,  and  its  recognition  is  likely  to  be 
obscured  by  the  predominant  signs  of  the  latter  condition. 

Valvular  lesions  are  often  combined,  in  which  case  double 
or  multipl'3  murmurs  will  result.  The  most  common  double 
lesions  are  : — 

(1)  Mitral  Stenosis  and  Reflux. 

(2)  Aortic  Reflux  and  Mitral  Reflux. 

(3)  Aortic  Reflux  and  Aortic  Stenosis. 

The  auriculo-ventricular  valves  are  liable  to  passive 
dilatation  consequent  upon  enlargement  of  the  heart  pro- 
duced by  other  lesions,  or  by  hypertrophy  consequent  upon 
increased  peripheral  resistance.  This  condition  produces 
the  blowing  systolic  murmur,  indicative  of  regurgitation 
through  the  valve  which  is  so  affected.  In  children  there 
is  also  a  diastolic  mitral  dilatation  murmur.  Common 
examples  of  passive  dilatation  are  : — 

(1)  Mitral  dilatation  secondary  to  aortic  valve  disease 
or  to  hypertrophy  from  arterio-sclerosis. 

(2)  Tricuspid  dilatation  secondary  to  mitral  diseases 
or  to  aortic  and  mitral  disease,  or  to  hypertrophy  of  the 
right  ventricle  consequent  upon  a  persistent  increase  in 
the  pulmonary  blood  tension  in  cases  of  emphysema. 
Arterial  Murmurs  not  conducted  from  the  heart  may 

occasionally   be    met   with   in    anaemia.     The   most   likely 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  217 

murmur  from  this  cause  is  a  soft  systoKc  bruit  in  the  left 
subclavian  artery. 

Where  the  aorta  is  congenitally  narrowed  at  the  level  of 
the  ductus  arteriosus  (coarctation  of  the  aorta)  a  systolic 
murmur  may  be  heard  over  the  manubrium  and  also  just 
to  the  left  of  the  vertebral  column  behind. 

Aneurysms  may  produce  a  systohc  murmur  or  occasionally 
a  double  murmur.  The  murmurs  are  heard  best  over  the 
aortic  area  and  manubrium,  and  are  not  conducted  down 
the  sternum.  They  are  only  likely  to  be  audible  when  the 
aneurysm  is  of  the  ascending  aorta.  The  systolic  murmur 
by  itseH  is  of  no  value  in  the  diagnosis  of  aortic  aneurysm. 

Venous  Murmurs  {bruit  de  diable)  in  the  great  veins  of  the 
neck  are  common  in  anaemia,  but  are  by  no  means  restricted 
to  this  condition.  They  are  modified  by  pressure  with  the 
stethoscope,  and  are  hea-rd  as  a  continuous  buzzing  sound 
varying  in  intensity  with  the  respiration. 

Exocardial  Sounds  must  not  be  mistaken  for  true  murmurs. 
The  most  likely  sources  of  error  are  : — 

(i.)  Pericardial  Friction.  This  may  be  mistaken  for  a 
double  aortic  murmur.  It  is,  however,  not  conducted,  as 
is  the  aortic  murmur,  along  the  lines  of  the  blood-stream  ; 
it  is  more  scratchy  in  character,  more  superficial,  and  can 
sometimes  be  modified  by  firm  pressure  with  the  stetho- 
scope ;   further,  it  is  continuous. 

(ii.)  Pleuro-pericardial  Friction.  This  is  commonly  heard 
at  the  upper  part  of  the  left  border  of  the  heart  ;  it  is 
modified  by  pressure  and  also  by  cessation  of  respiration. 

In  conclusion  we  would  emphasise  that  though  the  presence 
of  a  cardiac  murmur  indicates  either  a  blood  dyscrasia  or  a 
cardiac  lesion  and  the  study  of  the  murmur  shows  which  of 
these  conditions  is  present,  nevertheless  in  the  latter  case 
the  fact  that  there  is  a  murmur  is  no  indication  that  the 
heart  is  not  thoroughly  competent  to  do  the  work  required 
of  it  and  that  many  other  factors  must  be  considered,  both 
symptoms  and  signs,  before  condemning  a  patient  to 
invalidity  merely  because  a  cardiac  murmur  happens  to  be 
present. 

B.  Thrills.  The  most  common  thrill  is  the  presystoUc 
or  diastoUc  thrill  felt  at  the  apex  in  cases  of  mitral  stenosis. 


218  MEDICAL  DIAGNOSIS 

More  rarely  there  is  a  systolic  thrill  in  mitral  regurgita- 
tion. 

A  systolic  thrill  at  the  aortic  area  and  transmitted  to  the 
arteries  in  the  neck  is  suggestive  of  aortic  stenosis,  and 
similarly  a  systolic  pulmonary  thrill  is  indicative  of  pul- 
monary stenosis. 

A  diastolic  thrill  following  the  lines  of  conduction  of  an 
aortic  diastolic  murmur  is  not  very  unusual  in  cases  of 
aortic  reflux. 

A  soft,  tickling,  wavy  thrill  is  often  present  during  late 
diastole  over  the  diffuse  impulse  of  adherent  pericardium. 

A  sj^stolic  basal  thrill  may  occasionally  be  produced  by 
an  aortic  aneurysm. 

VI.    THE  PULSE  AND  BLOOD  PRESSURE. 

(i.)  The  Pulse.  Three  fingers  should  be  used  for  examin- 
ing at  the  same  time  the  pulss  and  the  quality  of  the  radial 
arteries  ;  the  frequency  of  the  pulse  and  its  regularity,  both 
of  force  and  rhythm,  are  readily  ascertained.  The  quality 
of  the  pulse  is  made  up  of  three  factors — namely,  the  size, 
the  tension,  and  the  mode  of  expansion.  Considerable 
experience  is  necessary  for  the  correct  estimation  of  these 
qualities.  The  tension  and  the  mode  of  expansion  are  esti- 
mated by  gradually  obliterating  the  pulse  with  the  topmost 
finger.  If  this  is  found  to  be  impossible  it  is  due  to  a 
free  anastomosis  with  the  ulnar  artery,  and  this  return  of 
blood  must  be  prevented  by  exercising  the  pressure  with 
the  lower-most  finger.  When  the  pulse  has  been  obliterated 
changes  in  the  arterial  wall  can  be  appreciated  by  rolling 
the   empty  vessel  beneath  the   middle  finger. 

The  frequency  of  the  pulse  is  increased  by  exercise  and 
also  by  fever,  the  ordinary  rate  of  increase  being  ten  beats 
per  minute  for  every  degree  rise  in  temperature.  When  the 
heart  is  extremely  dilated  many  of  the  systolic  contractions 
may  be  so  feeble  as  never  to  reach  the  wrist  ;  when  there  is 
the  slightest  possibility  of  this  being  the  case  the  radial 
frequency  should  be  carefully  checked  by  auscultation  of  the 
cardiac  impulse.  Rapidity  of  action  combined  with  irregu- 
larity are  significant  of  cardiac  insufficiency,  but  they  may 
also  occur   as   neurotic   features   of   hearts   the  valves  and 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM  219 

muscles  of  which  are  perfectly  healthy  and  also  in  condition 
of  chronic  toxaemia. 

The  size  of  the  pulse  is  very  variable  ;  it  is  large  in  febrile 
conditions,  in  some  cases  of  increased  peripheral  resistance, 
and  often  when  there  is  aortic  reflux.  It  is  small  when  the 
heart  is  failing  and  in  the  valvular  lesions  of  aortic  and  mitral 
stenosis. 

The  pulse  tension  is  high — that  is  to  say,  the  wave  is  not 
readily  obliterated — when  from  any  cause  the  peripheral 
resistance  is  increased  either  b}^  alteration  in  the  quality  of 
the  blood  or  by  arterial  spasm,  or  when  the  heart  is  hyper- 
trophied.  A  pulse  that  is  at  the  same  time  small,  hard, 
and  rapid  (wiry)  is  significant  of  peritonitis.  A  pulse  of  low 
tension — that  is  to  say,  one  that  is  readily  obliterated — is 
significant  of  myo-cardial  debility,  relaxation  of  the  arterioles, 
or  any  grave  debilitating  disease  such  as  enteric  fever  or 
chronic  pulmonary  tuberculosis. 

The  dicrotic  pulse  is  produced  by  an  abnormal  increase  in 
the  dicrotic  wave;  this  causes  an  apparent  doubling  of  the 
pulse  and  is  an  expression  of  extreme  low  tension.  It  is  most 
commonly  observed  in  enteric  fever.  The  dicrotic  notch  in  a 
healthy  pulse  is  produced  by  the  elastic  recoil  of  the  aortic 
walls  at  the  commencement  of  diastole.  Since  the  aortic 
valves  are  closed  at  this  time,  a  secondary  impulse  is  con- 
veyed to  the  blood  in  the  arteries.  For  the  production  of  a 
dicrotic  pulse  a  short,  feeble  systole  and  a  low  peripheral 
resistance  are  requisite. 

For  the  proper  appreciation  of  the  mode  of  expansion  of  a 
pulse  it  is  necessary  to  understand  the  normal  component 
parts  of  the  pulse  wave  (Fig.  41).  For  this  purpose  the 
tracings  made  by  the  sphygmograph  are  of  value.  The 
normal  pulse  tracing  shoAvs  an  uninterrupted  and  nearly 
vertical  upstroke  or  peicussion  wave  and  a  gradually 
sloping  downstroke  on  which  are  seen  two  definite 
irregularities.  The  upper  irregularity  is  produced  by  the 
tidal  Avave  which  ie})resents  the  actual  blood  pressure  within 
the  vessel.  The  fact  that  this  is  lower  than  the  primary  or 
jXTCussion  wave  is  due  to  the  momentum  imparted  to  the 
lever  by  the  ventricular  systoh^  carrying  the  pointer  too 
high.     The  lower  irregularity  or  dicrotic  notch  corresponds 


220  MEDICAL   DIAGNOSIS 

to  the  closure  of  the  aortic  valves  ;  the  rise  just  after  this 
notch  is  called  the  dicrotic  wave,  and  is  due  to  the  elastic 
recoil  of  the  aorta  at  the  beginning  of  diastole  following  its 
distension  at  the  moment  of  ventricular  contraction. 

It  will  thus  be  seen  that  cardiac  systole  is  represented  on 
the  pulse  tracing  as  the  line  between  the  base  line  and  the 
tidal  notch,  while  the  curve  from  the  tidal  notch  back  to  the 
base  line  represents  the  cardiac  diastole. 

A  pulse  of  normal  or  low  tension  is  described  as  a  kata- 
crotic  pulse — that  is  to  say,  the  percussion  stroke  ascends  to 
its  highest  point  in  an  unbroken  line.  Where,  however, 
there  is  a  mean  high  tension,  as  from  greatly  increased 
peripheral  resistance  and  a  strongly  acting  heart,  the  pulse 


Fig.  41. — Tracing  to  show  the  component  parts  of  the  normal 
Radial  Pulse  Wave. 

may  become  anacrotic  and  the  tidal  wave  may  be  as  high  or 
higher  than  the  percussion  wave  ;  the  result  of  this  is  a 
plateau  formation  on  the  pulse  tracing.  This  plateau  forma- 
tion is  also  seen  in  aortic  stenosis. 

The  pulse  of  low  tension  shows  an  exaggeration  of  the 
dicrotic  wave,  while  the  tidal  wave  is  slight  or  absent. 

The  alternation  of  large  and  small  beats  (bigeminal  pulse) 
in  all  probability  is  due  to  the  occurrence  of  an  extra  ventri- 
cular contraction  following  the  regular  beat,  and  is  likely  to 
be  caused  by  undue  excitability  of  the  ventricles  {vide  p.  244). 

More  marked  irregularity  of  the  pulse  in  which  no  two 
consecutive  beats  are  alike  is  commonly  seen  in  the  later 
stages  of  organic  heart  lesions  either  muscular  or  valvular 
(m/e  Auricular  Fibrillation,  p.  251). 

The  alterations  in  the  length  of  the  systole  so  commonly 
met  with  in  children  are  probably  due  to  retardation  impulses 
of  vagus  origin  {vide  p.  240). 

The  pulsus  paradoxus  consists  in  an  enfeeblement,  or  even 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   221 

disappearance,  of  the  radial  pulse  during  deep  inspiration. 
It  is  present  in  some  cases  of  adhesive  mediastinitis,  adlierent 
pericardium,  and  even  of  large  pericardial  effusion,  and  is 
presumably  due  to  hampering  of  an  unusually  weak  cardiac 
systole  by  the  increased  intra-thoracic  pressure  of  inspira- 
tion. 

The  features  of  the  pulses  belonging  to  the  different 
valvular  diseases  will  be  described  under  the  lesions  with 
which  they  are  connected. 

Venous  Pulse.  As  the  right  auricle  contracts  there  is 
normally  a  suction  wave  manifested  in  the  great  veins  of  the 
neck  ;  a  ventricular  systohc  pulsation  in  the  neck  veins  is, 
however,  diagnostic  of  tricuspid  reflux.  Under  such  circum- 
stances the  veins,  if  compressed,  will  fill  up  from  below. 
Transmitted,  pulsation  from  the  external  carotid  must  not  be 
mistaken  for  a  true  venous  pulsation. 

(ii.)  The  Blood  Pressure  depends  upon  the  peripheral 
resistance,  the  force  of  the  heart's  systole,  the  volumeC  of 
the  blood,  and  the  elasticity  of  the  vessels.  The  maximum 
systohc  pressure  can  be  measured  in  terms  of  miUimetres  of 
mercury  by  means  of  the  sphygmo-manometer.  This  appa- 
ratus consists  of  a  hollow  armlet  which  is  connected  with  a 
U-tube  containing  mercury  on  which  there  is  a  millimetre 
scale,  and  also  with  a  small  ball  pump.  The  armlet  is 
buckled  to  the  upper  arm  of  the  patient  and  filled  with  air 
until  the  radial  pulse  has  disappeared.  Air  is  now  permitted 
gradually  to  re-enter  the  armlet  by  means  of  a  screw  valve, 
and  at  the  moment  when  the  return  of  the  radial  pulse  is 
first  perceived  the  height  of  the  column  of  mercury  is  read 
on  the  scale.  This  reading  is  the  maximum  systohc  blood 
pressure. 

In  performing  the  experiment  the  arm  of  the  patient 
should  be  kept  on  a  level  with  his  heart. 

It  is  obvious  that  impairment  of  elasticity  by  calcification 
or  rigidity  in  the  radial  artery  must  influence  to  a  certain 
extent  the  readings  obtained.  There  is  no  unanimity  of 
opinion  as  to  the  extent  of  error  that  may  be  so  produced, 
but  it  is  probably  equivalent  to  not  more  than  ten  milli- 
metres of  mercury. 

The  blood  pressure  may  rise  with  exercise  or  excitement 


222  MEDICAL   DIAGNOSIS 

and  also  after  meals  ;  in  health  the  normal  blood  pressure 
of  an  infant  is  about  75  mm.  of  mercury,  of  children  up  to 
the  age  of  14  about  90  — 100  mm.,  of  young  adults  about 
115  mm.,  and  from  the  age  of  30  it  is  said  to  rise  from 
8  to  10  mm.  for  every  decade  up  to  50  or  60  years. 

High  readings  are  obtained  in  cases  of  nephritis,  arterio- 
sclerosis, gout,  lead  poisoning,  and  the  like  ;  low  readings  in 
acute  infective  diseases,  debilitated  conditions,  and  in  cases 
of  shock  or  haemorrhage. 

A  high  reading  is  usually  obtained  in  cases  of  aortic 
regurgitation,  which  is  misleading  because  the  mean  blood 
pressure  in  this  disease  must  be  low  ;  hence  it  is  a  pity  that 
it  is  so  difficult  to  measure  the  diastolic  pressure  and  so  to 
establish  the  mean  blood  pressure,  a  reading  which  would  be 
of  more  value  than  that  which  is  now  obtained.^ 

VII.    ACUTE  ENDOCARDITIS. 

By  acute  endocarditis  is  meant  microbic  invasion  of  the 
endocardium.  The  primary  site  of  infection  is  practically 
alM^ays  on  the  valve  cusps  about  xs  inch  from  their  free 
edges.  Endocarditis  is  divided  arbitrarily  into  Simple  and 
Ulcerative,  though  there  is  no  essential  difference  in  the 
pathology  of  the  two  conditions. 

Simple  endocarditis  is  a  much  milder  infection  than  the 
ulcerative  form.  As  a  rule  the  lesions  are  limited  to  a  fringe 
of  bead -like  vegetations  along  the  valve.  Ulceration  of 
these  vegetations  is  unnecessarj^  and  indeed  unusual.  In  the 
ulcerative  variety,  on  the  other  hand,  the  infection  is  much 
more  severe  ;  the  vegetations  are  much  larger  and  often 
spread  as  fungating  masses  to  the  walls  of  the  neighbouring 
heart  cavities. 

Simple  endocarditis  in  the  great  majority  of  cases  is  caused 
by  the  micro-organism  of  rheumatism,  though  it  may  occa- 
sionally accompany  scarlet  fever,  measles,  influenza,  etc. 
Ulcerative  endocarditis  is  caused  by  streptococci,  pneu- 
mococci,  staphylococci,  and  occasionally  gonococci  or  the 
bacilli  of  typhoid  fever. 

'  Many  sphygmo-manometers  are  on  the  market ;  the  one  described  is  the 
Riva-Rocci  pattern. 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   223 

(i.)  Simple  Acute  Endocarditis.  The  symptoms  are  likely 
to  be  obscured  by  those  of  the  primary  disease.  In  the  case 
of  rheumatism  continued  pyrexia,  despite  the  use  of  salicy- 
lates, may  be  suggestive.  For  the  most  part,  however,  the 
diagnosis  must  depend  on  the  appearance  of  physical  signs 
denoting  impaired  function  of  one  or  more  of  the  cardiac 
valves.  The  mitral  valve  is  most  commonly  affected,  then 
the  aortic  and  the  mitral,  and  lastly  the  aortic  alone  ;  it  is 
very  rare  for  the  right  heart  to  be  affected  primarily.  Since, 
then,  a  cardiac  murmur  is  likely  to  be  the  most  important 
evidence  of  endocarditis,  it  is  necessary  clearly  to  understand 
what  other  explanations  there  may  be  of  such  a  murmur. 

The  murmur  may  indicate  an  old  valvular  deformity 
resulting  from  a  previous  endocarditis  ;  in  such  a  case  the 
hypertrophy  of  the  heart,  as  well  as  the  history  of  previous 
attacks  of  rheumatism  and  perhaps  the  presence  of  rheumatic 
nodules,  may  assist  the  diagnosis. 

A  haemic  murmur  is  often  met  with  during  an  attaoJv  of 
rheumatism  :  the  point  of  maximum  intensity  of  this 
murmur  is  in  the  pulmonary  area,  and  the  knowledge  that 
the  pulmonarj^  valve  is  practically  never  affected  in  simple 
endocarditis  should  prevent  any  mistake. 

A  systolic  murmur  of  mitral  reflux  due  to  passive  dilata- 
tion from  myocarditis  is  very  common  in  rheumatism.  This 
condition  can  only  be  diagnosed  at  the  close  of  the  illness, 
when  as  the  heart  muscle  recovers  its  tone  the  murmur 
disappears,  whereas  true  endocarditis  will  produce  per- 
manent valvular  deformity  and  a  lasting  murmur  will  result. 
The  immediate  lesions  produced  by  simple  endocarditis  are 
nearly  alwa}s  regurgitative,  though  as  the  vegetations 
become  replaced  by  cicatricial  tissue  stenosis  may  develop. 

The  probability  of  there  being  active  endocarditis  is 
enhanced  if  there  is  a  distinct  alteration,  as  from  blowing  to 
musical,  of  a  mitral  systolic  murmur,  and  also  if  there  is  a 
persistent  mid-diastolic  mitral  murmur.  This  latter  mur- 
mur does  occur  sometimes  from  dilatation,  but  it  rarely 
persists  for  more  than  a  few  days  unless  there  is  thickening 
of  the  edges  of  the  mitral  curtains. 

Obscuring  of  the  aortic  second  sound  followed  by  the  soft 
diastolic  murmur  of  aortic  reflux  and  occurring  in  a  child 


224  MEDICAL   DIAGNOSIS 

can  hardly  mean  anything  else  than  active  endocarditis  of 
the  aortic  valves.  The  rapid,  irregular  pulse,  dyspnoea, 
palpitations,  and  increased  area  of  precordial  dulness  which 
are  present  in  acute  endocarditis  are  only  significant  of 
cardiac  dilatation,  and  are  therefore  of  but  little  service 
from  the  point  of  view  of  differential  diagnosis. 

(ii.)  Ulcerative  Endocarditis.  This  condition  is  a  true 
septicaemia  with  a  coincident  inflammatory  infection  of  the 
cardiac  valves  and  endocardium.  Although  the  left  heart  is 
affected  much  more  often  than  the  right,  nevertheless  the 
right  heart  is  not  so  immune  as  in  the  case  of  simple  endo- 
carditis. The  disease  is  most  common  in  the  third  and  fourth 
decades,  and  valves  aheady  damaged  by  previous  inflamma- 
tion are  more  liable  to  infection. 

The  Signs  and  Symptoms  fall  readily  into  two  groups  : — 
(a)  General  symptoms  of  septicaemia,  such  as  rigors, 

sweating,  wasting,   severe  anaemia,  purpuric  rashes,   an 

extremely  irregular,  intermittent  type  of  temperature,  and 

the  presence  of  micro-organisms  in  the  blood. 

(6)  Signs  of  cardiac  involvement,  such  as  dilatation, 

valvular  disease,  and  particularly  shifting  and  variable 

murmurs,  indicating  either  alteration  in  existing  lesions  or 

the  involvement  of  hitherto  unaffected  valves,  and  lastly 

evidence  of  embolism. 

In  very  exceptional  cases  there  may  be  no  evidence  of 
valvular  disease  ;  we  can  recall  two  cases  of  mitral  stenosis 
with  ulceration  of  the  left  auricle  and  ball-clot  formation,  in 
which  no  murmurs  were  heard  throughout  the  illness  though 
signs  of  cardiac  dilatation  were  present.  Variability  of 
murmurs  from  day  to  day  is  pathognomonic,  but  unfortu- 
nately is  not  a  constant  feature. 

Embolism,  and  especially  infective  embolism,  affords 
important  corroborative  evidence,  though  it  is  necessary  to 
remember  that  simple  infarction  is  common  in  mitral 
stenosis,  and  that  in  this  condition  pulmonary  infarcts  are 
particularly  frequent. 

The  symptoms  of  the  more  common  forms  of  infarction 
may  briefly  be  considered  in  this  connection  :  — 

(i.)  Pulmonary  Embolism  is  commonly  produced  by  the 
di^ocation  of  clot  formed  in  the  right  auricular  appendix  ; 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  225 

sometimes   it   follows   systemic    venous  thrombosis    or   an 
infective  lesion  of  the  pulmonary  valve. 

A  large  pulmonary  embolus  produces  sudden  precordial 
pain,  extreme  dyspnoea  without  obvious  impairment  of  air 
entry,  cyanosis,  and  a  rapid,  irregular  action  of  the  heart, 
followed  by  pallor,  convulsions,  and  death  in  a  few  moments. 


KJ 

1!! 

9. 
1 

1 

r 
10  s' 
los' 

10^ 
103° 

m' 

101' 
100° 
19' 

}e° 

97° 

96° 

130 

no 
no 

100 
90 

so 

70 

so 
-so 

5S 

■iS 
35 
2S 

M    E 

M    E 

M    E 

M   E 

M    E 

ME 

M  E 

M  E 

ME 

ME 

M  E 

M  E 

M  E 

ME 

M  E 

M   E 

M    E 

ME 

M  E 

M  E 

ME 

; 

: 

.^ 

: 

\ 

S 

:/ 

■  b 

A 

r 

A 

^ 

J 

■■ 

^ 

\ 

A 

A 

N 

y. 

/^ 

I 

M 

/ 

\ 

■P 

■  :  \ 

{ 

1 

— ^" 

Lk^ 

4- 

... 

L.. 

.1. 

■/- 

__\ 

"l~ 

--- 

w 

fF~ 

■V- 

^3' 

-mm 

-w 

••*- 

>i»i 

•  •_ 

•-. 

V: 

1 

/■ 

V 

V 

\ 

^ 

:  V 

v 

; 

/ 

v' 

■/I 

r 

\ 

/ 

: 

:/ 

:V 

}. 

■  h 

■  fl 

A 

/ 

,     A 

j 

\ 

/ 

/ 

V: 

/^ 

■r 

A 

/- 

\^ 

v^ 

^ 

V 

T 

Y. 

\   . 

f\ 

^ 

7 

■v 

/ 

^ 

si 

■^^ 

■  1  : 

■ 

: 

> 

: 

i^ 

./ 

\i^ 

X. 

^^ 

^r^w-A 

/     ■- 

"^^ 

-^ 

^■ 

; 

, 

.^ 

J 

V 

V 

y 

\ 

^ 

■^ 

■ 

' 

Fig.  42. — Chart  from  a  case  of  Ulcerative  Endocarditis. 


Infarction  of  the  smaller  vessels  causes  sudden  pain  in 
the  chest,  with  cough,  haemoptysis,  dyspnoea,  and  moderate 
pyrexia.  Often  there  is  localised  pleurisy  with  or  without 
effusion,  and  there  may  be  evidence  of  a  suiall  area  of  solid 
lung. 

Sometimes  hicmoptysis  is  the  only  symptom,  while  if 
the  infarct  is  very  small  there  may  be  no  evidence  of  its 
existence. 

M.D.  15 


226  MEDICAL   DIAGNOSIS 

Pulmonary  apoplexies  are  not  ahva^'s  embolic  ;  they  may 
sometimes  be  produced  by  gradual  arterial  thrombosis  in 
cases  of  chronic  cardiac  insufficiency,  especially  when  there 
is  mitral  obstruction. 

(ii.)  Splenic  Embolism  may  give  rise  to  no  symptoms  ; 
commonly  there  is  enlargement  of  the  spleen,  and  often 
there  is  a  sharp  pain  in  the  lower  part  of  the  left  chest  and 
a  sudden  rise  in  temperature,  while  a  friction  rub  may  be 
audible  in  this  situation.  Enlargement  of  the  spleen  from 
toxaemia  is  of  frequent  occurrence  in  infective  endocarditis. 

(iii.)  Renal  Etnbolism  may  cause  severe  pain  in  the  loin, 
and  is  often  accompanied  by  hsematuria  and  pyrexia. 

(iv.)  Cerebral  Embolis?ri  usually  produces  a  sudden 
hemiplegia,  but  the  extent  of  the  paralysis  naturally  depends 
on  the  situation  of  the  embolus.  Consciousness  is  not 
necessarily  lost.  The  left  side  of  the  brain  is  more  liable  to 
embolism  than  the  right. 

(v.)  Mesenteric  Embolism  is  accompanied  by  sudden 
severe  abdominal  pain,  quickly  followed  by  vomiting  and 
tjanpanites.     There  is  often  mala3na  after  a  short  interval. 

(vi.)  Embolism  of  the  Peripheral  Arteries  usually  causes 
sudden  pain  in  the  affected  limb  with  obliteration  of  the 
pulse  beyond  the  lesion.  The  limb  may  be  pale  and  cold, 
but  there  is  not  often  oedema,  and  the  collateral  circulation 
is  usually  established  after  a  short  interval.  In  rare  cases 
gangrene  may  result,  but  not  unless  there  is  extensive 
arterial  disease  co -existing. 

Differential  Diagnosis.  Ulcerative  endocarditis  may  pre- 
sent widely  diverse  clinical  pictures.  The  diseases  with 
which  it  is  most  likely  to  be  confounded  are  :— - 

(i.)  Enteric  Fever  {vide  p.  23). 

(ii.)  Generalised  Tuberculosis,  In  the  absence  of  variable 
cardiac  murmurs  (for  a  patient  with  tuberculosis  may  quite 
possibly  have  old  valvular  disease)  or  definite  evidence  of 
a  "  tuberculous  lesion,"  the  diagnosis  may  be  extremely 
difficult.  A  high  polymorphonuclear  leucocyte  count  would 
favour  septicaemia,  while  a  preponderance  of  lymphocytes 
would  favour  tuberculosis.  A  positive  blood  culture  experi- 
ment would  of  course  settle  the  question  {vide  infra). 

(iii  )  Malaria.     Occasionallv  for  a  few  days  the  tempera- 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM   227 

turc  of  infective  endocarditis  may  remit  in  a  manner  so 
regular  as  to  simulate  malaria.  The  absence  of  leucocytosis 
and  the  reaction  to  quinine,  as  well  as  the  discovery  of  the 
Plasmodium  in  the  blood,  should  prevent  error  for  more  than 
a  short  while. 

(iv.)  Basal  Meningitis.  In  the  absence  of  cardiac 
murmurs  this  condition  may  be  simulated.  Lumbar 
puncture  with  the  examination  of  the  cerebro-spinal  fluid 
will  quickly  settle  the  question  {vide  p.  512). 

In  all  cases  the  attem2)t  should  be  made  to  cultivate  the 
causative  micro-organism  from  the  blood  of  the  patient, 
})oth  from  the  point  of  view  of  establishing  the  diagnosis  and 
also  in  order  to  prepare  a  vaccine  for  purposes  of  treatment. 

At  least  10  c.c.  of  blood  should  be  withdrawn  by  veni- 
puncture and  promptly  added  to  50  c.c,  of  sterile  broth. 
The  mixture  should  be  incubated  at  37°  C,  and,  if  any 
growth  result,  sub-cultures  on  agar  tubes  and  other 
nutrient  media  may  be  made  for  the  identification  of  the 
organism.  The  original  broth  should  be  kept  in  the 
incubator  for  seventy-two  hours  before  hope  is  abandoned, 
since  some  of  the  streptococci  may  take  this  time  to  grow 
{vide  ai,so  p.  157). 

The  isolation  in  this  manner  of  an  organism  from  the  blood- 
stream of  a  patient  is  proof  positive  of  septicsemia,  but  does 
not  necessarily  indicate  ulcerative  endocarditis.  In  the 
absence  of  any  discoverable  septic  focus,  even  if  there  be 
no  very  definite  cardiac  sign,  the  diagnosis  of  ulcerative 
endocarditis  is  strongly  suggested  if  a  definite  organism 
can  be  cultivated  from  the  blood,  and  especially  if  infarction 
occurs. 

VIII.    THE  DIAGNOSIS  OF  VALVULAR 

LESIONS  ( Chronic  Endocarditis). 

In  consideration  of  the  individual  valvular  lesions  it 
must  be  remembered  that  both  mitral  and  aortic  lesions 
occurring  in  young  people  arc  ncarl}^  always  due  to 
rheumatic  endocarditis,  but  that  rheumatism  occurring 
for  the  first  time  in  adult  life  is  not  so  prone  to  be  asso- 
ciated with  pernument  cardiac  affections.     Therefore    the 

15—2 


228  MEDICAL   DIAGNOSIS 

onset  of  valvular  disease  in  the  second  half  of  life  is  likely 
to  be  atributable  to  other  causes,  such  as  fibrosis  of  the 
heart  muscle.,  arterio-sclerosis,  syphilis,  or  strain. 

Tricuspid  reflux  is  a  natural  sequel  of  mitral  disease  or 
of  chronic  pulmonary  lesions  ;  it  is  probable  also  that  to  a 
certain  extent  it  is  a  physiological  occurrence  at  times  of 
severe  physical  exertion. 

Tricuspid  stenosis  is  not  common  and  does  not  occur  apart 
from  mitral  stenosis,  the  signs  of  which  are  so  much  more 
prominent  that  the  former  condition  may  not  be  detected. 

Pulmonary  regurgitation  is  so  rare  as  to  be  negligible  ; 
it  maybe  produced  by  ulcerative  endocarditis.  Pulmonary 
stenosis  is  only  met  with  as  a  congenital  lesion  or  possibly 
in  infective  endocarditis. 

The  valvular  lesions  will  now  be  considered  individually. 

(i.)  Mitral  Reflux.  Symptoms.  There  are  no  symp- 
toms so  long  as  the  cardiac  muscle  is  able  to  hypertrophy 
sufficiently  to  perform  adequately  the  increased  work  it  is 
called  upon  to  do. 

The  earliest  symptom  to  appear  will  be  an  abnormal 
breathlessness  on  exertion,  the  result  of  the  inability  of  the 
right  heart  to  cope  with  any  extra  stress  ;  at  the  same  time 
the  acceleration  of  the  pulse  after  exercise  will  take  longer 
to  subside  than  in  health.  In  more  advanced  stages  the 
symptoms  will  still  point  to  engorgement  and  hypertension 
of  the  pulmonary  blood  system,  and  there  will  be  permanent 
dyspnoea  and  cough,  sometimes  with  hsemoptysis. 

As  the  right  ventricle  fails  under  the  increasing  strain  the 
right  auricle  becomes  engorged  and  the  congestion  is  com- 
municated to  the  systemic  veins  :  oedema  is  the  result.  The 
cough  becomes  more  marked,  the  dyspnoea  becomes 
orthopnoea,  the  liver  becomes  swollen  and  painful  and  may 
pulsate,  and  the  urine  becomes  scanty,  high  coloured,  and 
albuminous. 

Physical  Signs.  The  cardiac  dulness  is  increased  to  the 
left  and  also  to  the  right  of  the  sternum  ;  the  impulse  is 
displaced  outwards  and  slightly  downwards  from  enlarge- 
ment of  both  ventricles,  and  except  in  slight  cases  it  is  more 
diffuse  than  usual.  The  pulsation  is  forcible  and  heaving 
and  is   often   well   marked  in  the   epigastrium  below   the 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   229 

costal  margin,  when  it  is  largeh^  produced  by  the  right 
ventricle. 

The  murmur  is  systolic  in  time  ;  it  is  best  heard  at  the 
apex,  is  conducted  out  into  the  axilla,  and  can  be  picked  up 
again  between  the  scapular  angle  and  the  vertebral  column. 
It  may  accompany  the  first  sound  or  it  may  replace  it ;  it  is 
often  soft  and  blowing,  but  may  be  harsh  or  musical. 

The  pulmonary  second  sound  is  accentuated  and  may  be 
reduplicated.  As  the  right  ventricle  fails  the  accentuation 
of  the  second  sound  disappears. 

The  pulse  is  strikingly  irregular  when  the  lesion  is  very 
marked. 

Free  regurgitation  through  the  mitral  ring  is  indicatedby: — 

(1)  Great  enlargement  of  both  ventricles. 

(2)  Replacement  of  the  first  sound  by  the  murmur. 

(3)  Great  accentuation  of  the  pulmonary  second  sound. 

(4)  A  forcible  impulse  with  a  weak  small  pulse,  showing 
that  the  blood  cannot  all  be  driven  into  the  arteries,  and 
therefore  that  a  good  deal  of  it  must  go  back  into  the  left 
auricle. 

(ii.)  Mitral  Stenosis.  Symptoms.  The  symptoms  are  the 
same  as  those  of  mitral  reflux,  with  the  exception  that  there 
is  more  liability  to  haemoptysis  from  the  more  sustained 
high  pressure  in  the  pulmonary  arteries,  and  also  to  embolism, 
both  pulmonary  and  systemic.  CEdema  does  not  occur  so 
readily  as  in  mitral  reflux,  but  ascites  is  peculiarly  likely. 

Physical  Signs.  The  right  ventricle  is  enlarged,  and  some- 
times an  enlargement  of  the  left  auricle  can  bo  appreciated 
by  percussion.  The  impulse  is  slapping  in  character,  and  is 
not  displaced  unless  it  be  very  slightly  to  the  left. 

The  most  common  murmur  is  presystolic  in  time.  It  is  a 
short,  rough  murmur,  runs  up  to  a  sharp  first  sound,  is  best 
heard  internal  to  the  impulse,  and  is  not  conducted  out  into 
the  axilla.  Other  diastolic  murmurs  may  be  present  at  the 
mitral  area — viz.,  the  mid-diastolic,  which  is  a  short  murmur 
caused  by  ventricular  suction  and  which  resembles  very 
closely  a  redu])licated  second  sound,  and  the  early  diastolic 
murmur,  which  may  perhaps  be  produced  by  recoil  of  the 
pulmonary  veins.  If  all  these  murmurs  are  present  at  the 
same  time  a  continuous  diastolic  rumble  will  result. 


230  MEDICAL   DIAGNOSIS 

A  systolic  murmur  at  the  mitral  area,  poorly  conducted 
and  not  audible  behind,  is  often  present  ;  indeed,  according 
to  Graham  Steel,  it  is  a  very  common  murmur  of  mitral 
stenosis. 

There  is  often  a  thrill,  presystolic  or  diastolic  ;  the 
pulmonary  second  sound  is  exaggerated  and  often  re- 
duplicated. 

The  pulse  is  regular,  but  small  and  of  high  tension  ;  it  is 
sometimes  anacrotic,  and  the  downstroke  is  long  and  gradual. 

The  signs  of  mitral  stenosis  are  by  no  means  constant. 
No  murmur  may  be  present  at  certain  stages,  and,  again,  the 
second  sound  may  disappear  entirely  at  the  apex. 

It  will  be  convenient  to  mention  the  three  stages  of  mitral 
stenosis  as  described  by  Broadbent,  though  they  do  not  occur 
in  every  case. 

First    Stage.     Presystolic    murmur,    first    sound,    and 

second  sound. 

Second  Stage.     Presystolic   murmur   and   short,   sharp 

first  sound,  but  no  second  sound. 

Third  Stage.     Short,  sharp  first  sound,  no  muruiur  and 

no  second  sound. 

The  short,  sharp  first  sound  is  often  sufficient  by 
itself  for  the  diagnosis  of  mitral  stenosis ;  it  is  probably 
produced  by  the  ventricular  wall  being  thrown  into  a 
sudden  state  of  tension  by  contracting  before  its  cavity  is 
full  of  blood. 

The  disappearance  of  the  second  sound  is  perhaps  due  to 
the  large  right  ventricle  rotating  the  left  ventricle  away  from 
the  chest  wall,  and  partly  also  to  the  poor  quality  of  the  aortic 
second  sound. 

The  disappearance  of  the  presystolic  murmur  is  due  to 
distension  of  the  auricle  hampering  or  even  abolishing  its 
power  of  contraction. 

It  is  important  to  time  the  sounds  and  murmurs  carefully, 
otherwise  when  the  second  sound  has  gone  the  shortened 
first  sound  may  be  mistaken  for  a  normal  second  sound  and 
the  presystolic  murmur  for  a  s^^stolic  one. 

(iii.)  Aortic  Reflux.  Symptoms.  Muscular  weakness, 
pallor,  faintness,  dyspnoea,  both  on  exertion  and  paroxysmal, 
insomnia,   and  sometimes  precordial  pain  or  even  angina 


DISEASES  OF  THE  CARDIOVASCULAR  SYSTEM   231 

pectoris.  Dyspepsia  is  common  as  in  all  cardiac  disease, 
and  vomiting  may  be  very  troublesome.  In  those  cases  in 
which  the  patients  do  not  die  of  s3'ncope  or  exhaustion  the 
mitral  valve  may  become  dilated  .from  the  great  size  of  the 
left  ventricle,  and  all  the  phenomena  of  back  pressure,  as  in 
the  later  stages  of  mitral  reflux,  may  ensue. 

Physical  Signs.  The  heart  is  enlarged  downwards  and  to 
the  left  ;  the  impulse  may  be  in  the  sixth  or  seventh  space, 
and  is  extremely  forcible.  The  characteristic  murmur  is  a 
soft  diastolic  murmur,  best  heard  at  the  aortic  cartilage,  over 
the  centre  of  the  manubrium,  or  in  the  pulmonary  area,  or 
even  at  the  lower  end  of  the  sternum  on  either  side.  It  is 
conducted  across  the  ba.se  of  the  heart  down  either  side  of 
the  sternum  and  towards  the  apex,  where,  indeed,  it  is  often 
audible.  Although  the  murmur  is  usually  soft,  it  may  be 
quite  loud,  and  in  those  cases  which  are  caused  by  sudden 
rupture  of  the  cusp  the  murmur  can  often  be  heard  several 
feet  away  from  the  patient.  / 

The  diastolic  murmur  accompanies  or  closely  follows  or 
entirely  replaces  the  aortic  second  sound.  There  is  often  a 
loud  systolic  aortic  murmur  conducted  up  into  the  vessels  of 
the  neck,  not  necessarily  due  to  stenosis,  but  more  often  to 
roughening  or  puckering  of  the  aortic  cusps  or  to  dilatation 
of  the  first  part  of  the  aorta.  When  both  .sA^stolic  and 
diastolic  murmurs  are  present  the  characteristic  to-and-fro 
double  aortic  murmur  is  produced.  The  presystolic  aortic 
reflux  murmur  of  Flint  has  been  described  (p.  215). 

The  aortic  second  sound  is  feeble,  impure,  or  absent. 

The  arteries  as  a  whole,  but  particularly  in  the  neck,  can  be 
seen  to  throb  violently,  and  capillary  pulsation  is  often 
marked.  This  can  be  demonstrated  by  pressing  a  glass  slide 
on  the  mucous  membrane  of  the  lip,  when  the  pulsations  can 
be  seen  at  the  margin  of  the  compres.sed  area. 

The  pulse  is  delayed  and  has  the  verj'  significant  collapsing 
or  ''  waterhammer  "  character.  It  is  large  in  volume  and  can 
be  felt  to  come  forcibly  up  against  the  finger,  but  it  is  very 
poorly  sustained,  and  the  artery  can  be  felt  to  empty 
completely  between  the  beats.  The  characteristics  of  this 
pulse  are  best  demonstrated  by  raising  the  patient's  hand 
above  his  head  and  by  completely  encircling  his  wrist  with 


232 


MEDICAL  DIAGNOSIS 


the  hand  and  fingers  so  as  to  appreciate  the  ulnar  pulse  as 
well  as  the  radial. 

The  pulse  of  children  with  aortic  reflux  is  not  nearly  so 
characteristic  as  that  of  adidts.  This  is  due  to  the  greater 
elasticit}^  of  the  blood-vessels  of  young  people. 

The  features  of  the  pulse  may  be  masked  if  the  arteries 
are  markedly  thickened  or  it  there  is  co-existing  aortic 
stenosis. 

Extensive  regurgitation  is  indicated  by  : — 

(1)  Much  arterial  pulsation. 

(2)  Very  collapsing  pulse. 

(3)  Replacement  of  aortic  second  sound  by  murmur 
and  consequent  absence  of  the  second  sound  in  the  neck. 

(4)  Great  enlargement  of  the  left  ventricle. 


Fig.  -i'd. — Radial  pulse  tracing  from  a  case  of  Aortic  Reflux. 


The  maximum  systolic  blood  pressure  as  measured  with 
a  sphygmo-manometer  is  often  high,  but  since  the  diastohc 
pressure  must  be  extremely  low,  it  follows  that  the  mean 
pressure  is  below  the  normal.  An  important  point  is  the 
wide  difference  in  the  blood  pressure  readings  in  the  arm 
and  leg  in  this  disease  ;  the  leg  reading  may  be  100  mm.  or 
more  higher  than  that  of  the  arm. 

(iv.)  Aortic  Stenosis.  Symptoms.  Pallor,  muscular 
weakness,  dyspnoea,  and  faintness.  Later  on  when  the  left 
ventricle  dilates  the  signs  and  symptoms  of  mitral  disease 
will  be  superadded. 

Physical  Signs.  In  the  early  stages  there  is  pure  hyper- 
trophy of  the  left  ventricle  ;  later  on  there  is  dilatation  also. 
The  impulse  is  displaced  downwards  and  very  slightly  out- 
wards ;  it  is  powerful  and  somewhat  diffused. 

The  murmur  is  a  rough  systolic  murmur,  heard  best  at  the 
aortic  cartilage  and  conducted  up  into  the  vessels  of  the 
neck,  and,  by  reason  of  its  loudness,  often  heard  over  the 


DISEASES  OF  THE  CARDIOVASCULAR  SYSTEM   233 

entire  prsecordium.  It  is  usually  accompanied  by  a  systolic 
thrill  localised  to  the  aortic  area. 

The  pulse  is  small  and  often  anacrotic,  with  a  gradual 
rise  and  a  distinct  sj'stohc  plateau. 

Since  true  aortic  stenosis  is  a  rare  condition,  it  is  not 
possible  to  base  a  diagnosis  of  it  on  the  presence  of  the 
murmur  alone.  The  size  and  shape  of  the  left  ventricle, 
the  presence  of  a  thrill,  the  nature  of  the  second  sound, 
and,  above  all,  the  character  of  the  pulse  must  all  be  care- 
fully considered.  As  before  mentioned,  an  aortic  systolic 
murmur   is    very   common  in   advanced   life,  and   may  be 

produced  by  roughening  of  the  aortic  cusps,    

by  atheroma,  or  by  dilatation  of  the  ascend-  ^^  p,^^  _,^ 

ing  aorta.  If  there  is  real  stenosis,  the  '  ^  V  v  v 
cusps  are  likely  to  be  so  bound  down  that  ^'tnf  fi^m^'^r  *casc 
the    second    soimd    becomes    feeble    and       cf  Aortic  Stenosis. 

1    11     1  Note     the    rounded 

'•^"^^^'^^-  systolic      plateau 

In  voung  people  an  aortic  systolic  mur-       ''nd  ths  gradual 

1      1         .       .£•         .       <•  •  descent. 

mur  may  only  be  signincant  of  anannui. 

(v.)  Pulmonary  Reflux.  This  lesion  does  not  produce 
any  definite  symptoms.  The  murmur  is  a  diastolic  murmur 
accompanying  or  replacing  the  pulmonary  second  sound, 
best  heard  in  the  third  left  space  and  conducted  down  the 
left  border  of  the  sternum.  The  right  ventricle  is  hypcrtro- 
phied.  The  character  of  the  aortic  second  sound,  the  size 
of  tlie  left  ventricle,  and  the  condition  of  the  pulse  and 
arteries  should  prevent  confusion  between  aortic  and  pul- 
monary reflux. 

(vi.)  Pulmonary  Stenosis.  Vide  "Congenital  Heart 
Lesions,"  p.  255. 

(vii.)  Tricuspid  Reflux.  This  condition  is  practically 
always  secondary  to  other  cardiac  lesions,  but  in  addition 
to  the  signs  and  symptoms  of  the  primary  lesion  tricuspid 
reflux  can  be  diagnosed  by  the  systemic  venous  engorgement 
and  the  systolic  venous  pulse  in  the  veins  of  the  neck, 
which  fill  up  from  below.  Another  certain  sign  is  a  pul- 
sating liver,  which,  however,  must  not  be  confused  with  a 
liver  which  receives  a  transmitted  pulsation  from  an  hyper- 
trophicd  right  ventricle.  The  expansion  of  a  pulsating 
liver  can  be  appreciated  by  bimanual  examination  with  the 


234  MEDICAL   DIAGNOSIS 

left  hand  in  the  loin  and  the  right  hand  over  the  costal 
margin. 

The  nivumin"  of  tricuspid  reflux  is  systolic  in  time  and  is 
best  heard  in  the  fifth  left  space  close  to  the  sternum  ;  it  is 
conducted  out  towards  the  apex  as  far  as  the  left  border  of 
the  right  ventricle,  but  no  further.  This  murmur  is  not 
always  present.  General  anasarca  is  a  common  accom- 
paniment of  tricuspid  reflux,  but  is  not  a  necessary  adjunct. 

(viii.)  Tricuspid  Stenosis  is  usually  masked  by  the  coin- 
cident mitral  stenosis. 

The  murmur,  if  audible,  is  presystolic  in  time  and  localised 
to  the  tricuspid  area.  Chronic  distension  of  the  jugular  veins 
without  systolic  pulsation  might  be  an  important  sign. 

IX.    THE   DIAGNOSIS   OF   HYPERTROPHY  AND 
DILATATION. 

(i.)  Hypertrophy.  This  must  not  be  regarded  as  a  patho- 
logical condition;  it  is  in  all  cases  beneficial,  since  it  indicates 
that  the  heart  is  able  to  deal  with  the  work  imposed  upon 
it.  Of  course,  the  fact  that  the  heart  is  hypertrophied 
is  a  sure  indication  that  the  work  done  is  in  excess  of  the 
normal,  and  the  cause  of  this  necessity  foi  increased  work 
is,  in  many  cases,  pathological. 

The  Left  Ventricle  will  become  hypertrophied  from  the 
following  causes  : — 

(  Aortic  reflux. 
{a)  Valvular  disease   . .     Aortic  stenosis. 

[  Mitral  reflux. 

/  Coronary  artery  obstruction. 
(6)  Other  cardiac  lesions  \  Cardiac  fibrosis. 

i  Adherent  pericardium. 

,  ,  ^^.  -  -  T      T  (  Renal  disease. 

(c)  High  blood  pressure  -    .   ,     .        , 

°  ^  [  Arterio-sclerosis. 

(d)  Imperfect  nervous 
control,  e.g.,  Tachy- 
cardia in  Graves' 
disease,  etc. 

(e)  Prolonged  strain  and  (  Soldiers, 
over-exertion  .  .  i  Athletes. 


DISEASES  OF  THE  CARDIO-VASCXFLAR  SYSTEM   235 

The  Left  Auricle  is  hypertrophied  in  mitral  disease,  but 
especially  in  mitral  stenosis. 

The  Right  Ventricle  is  hypertrophied  in  : — 

f  Mitral  stenosis. 

Mitral  reflux. 

{a)  Valvular  disease   .  .  ^  Tricuspid  reflux, 

]  Pulmonary  stenosis. 

I  Pulmonarj^  reflux. 

,,,^,,  ,.      ,     .        (  Adherent  pericardium. 

(6)  Other  cardiac  lesions     t^.,       •      p  , 

^  '  (  fibrosis  ot  heart. 

(  Chronic  bronchitis. 

(c)  Chronic   pulmonary  -!  Emphysema. 

lesions  . .  . .  i  Fibroid  lung. 

The  Right  Auricle  is  hypertrophied  : — 

(a)  Secondary  to  right  ventricle  hypertrophy  from  any 

cause  and  consequent  tricuspid  reflux.  ' 

{h)  Primary  tricuspid  reflux  ;    tricuspid  stenosis. 

Symptoms  of  hypertrophy  are  usually  absent.  There 
may  be  consciousness  of  the  heart's  action  and  more  or  less 
insomnia.  When  symptoms  appear  it  usually  means  that 
there  is  commencing  dilatation. 

The  Physical  Signs  of  hypertrophy  of  the  left  verifricle 
are  : — 

(a)  Displacement  of  impulse  downwards  and  outwards. 

(h)  Increased  percussion  area  downwards  and  to  the  left. 

(c)  Powerful,  heaving  and  rather  diffuse  impulse. 

{d)  Prolonged,  low-pitched  first  sound  at  apex  and  at 
aortic  area  ;  accentuated  ringing  and  sometimes  reduplicated 
aortic  second  sound. 

(e)  The  pulse  varies  with  the  cause  of  the  hypertrophy. 
Except  in  certain  valvular  diseases  the  pulse  will  be  of  high 
tension  and  incompressible,  with  a  gradual  rise  and  a 
rounded  summit.  The  artery  is  likely  to  be  easily  palpable 
between  the  beats. 

Hypertrf)phy  of  the  right  ventricle  is  shown  by  reduplica- 
tion or  accentuation  of  the  pulmonary  second  sound  ;    it  is 
^  not  easy  to   percuss  out  an  hypertrophied  right  ventricle 
unless   there   is   dilatation   as  Avell,   but    a  diffuse   heaving 


236  MEDICAL   DIAGNOSIS 

impulse  under  the  xiphisternum  is  suggestive  of  this 
condition. 

(ii.)  Dilatation  of  the  heart  may  be  beneficial  up  to  a 
point  ;  indeed,  it  is  necessary  in  most  cases  of  valvular 
disease.  When,  however,  the  dilatation  is  in  excess  of  the 
accompanying  hypertrophy  grave  issues  are  at  hand. 

Any  condition  which  tends  to  require  an  increasing  amount 
of  cardiac  hypertrophy  will  sooner  or  later  produce  a  con- 
dition of  clinical  dilatation. 

Dilatation  may,  however,  be  produced  primarily  b}^  the 
action  on  the  myocardium  of  the  toxins  of  infectious  diseases, 
such  as  diphtheria,  enteric  fever,  rheumatism,  etc.,  or  certain 
chemical  poisons,  such  as  alcohol  and  tobacco,  by  unaccus- 
tomed and  protracted  exertion,  and  lastly  by  severe 
emotional  crises. 

The  Early  Symptoms  of  cardiac  dilatation  are  : — Debility, 
both  mental  and  physical,  insomnia,  bad  dreams,  and  espe- 
cially breathlessness  on  any  exertion.  Later  on  paroxysmal 
dyspnoea,  palpitation,  cyanosis,  coldness  of  the  extremities, 
cardiac  oedema,  enlargement  of  the  liver,  and  scanty  urine  are 
likely  to  be  met  with. 

The  Physical  Signs  are  : — An  increase  horizontally  in  the 
area  of  cardiac  dulness,  a  diffuse  indeterminate  impulse,  a 
short,  sharp  first  sound,  and  a  rapid,  irregular,  and  soft  pulse. 

Such  cardiac  murmurs  as  are  present  may  indicate  some 
primary  valvular  lesion,  or  they  may  be  systolic  dilatation 
murmurs.  In  the  earlier  stages  of  dilatation  the  systolic 
period  is  likely  to  be  prolonged  at  the  expense  of  diastole 
producing  a  "  tic-tac ''  rhythm  ;  but  in  the  more  severe  stages 
the  heart  sounds  appear  too  close  together,  and  at  the  same 
time  the  diastole  is  shortened. 

Qildema  of  the  lungs,  effusions  into  the  serous  cavities, 
embolism,  gastric  catarrh,  and  Cheyne-Stokes  respiration  are 
all  significant  accompaniments  of  extreme  cardiac  dilatation. 

For  the  differential  diagnosis  of  Dilated  Heart  from 
Pericardial  Effusion,  vide  p.  259. 

X.   MYOCARDIAL  DEGENERATIONS. 

These  may  be  divided  into  Toxic  and  Degenerative.     li\ 
the  former  group  are  included  the  results  of  the  infective 


DISEASES  OF  THE  CAllDIO-VASCULAR  SYSTEM   237 

diseases,  such  as  rheumatism,  influenza,  diphtheria,  as  well 
as  the  grave  anaemias,  phosphorous  poisoning,  etc.  ;  in  the 
latter  the  results  of  gummatous  deposits,  subacute  myocar- 
ditis, and  the  occlusion  of  the  coronary  arteries  by  atheroma 
or  by  endarteritis,  by  embolism  or  thrombosis. 

The  acute  fevers  produce  cloudy  swelhng,  with  more  or 
less  granular  degeneration  and  sometimes  a  certain  amount 
of  fatty  change. 

The  grave  anaemias,  phosphorous,  arsenic,  and  alcohol  are 
likely  to  produce  extensive  fatty  degeneration. 

Coronary  obstruction,  when  of  gradual  occurrence,  is 
followed  by  fibrous  transformation  and  also  by  fatty 
degeneration  in  varying  proportions. 

Coronary  embolism,  in  the  absence  of  sudden  death,  is  of 
course  followed  b}^  infarction  of  the  heart  wall.  Softening  in 
the  infarct  is  likely  to  produce  an  aneurysm  of  the  heart. 

The  symptoms  of  the  cardiac  degeneration  are  those  of 
myocardial  insufficiency  and  dilated  heart.  They  inclutle 
dyspnoea,  palpitations,  precordial  pain,  often  paroxysmal, 
sense  of  oppression,  and  frequently  more  or  less  cardiac 
oedema. 

The  Physical  Signs  are  : — An  increase  horizontally  in  tiie 
area  of  cardiac  dulness,  a  diffuse  feeble  impulse,  arrhythmia, 
and  a  shortening  of  the  first  sound.  Soft  dilatation  murmurs 
may  be  heard.  Later  on  the  first  sound  may  disappear, 
and  serous  effusions  and  pulmonary  oedema  may  become 
manifest.  The  pulse  is  often  slow,  but  in  practically  all 
(^ases  the  outstanding  feature  is  its  irregularity. 

l5oth  fibroid  and  fatty  hearts  are  liable  to  cause  sudden 
death  with  or  without  a  preceding  illness,  and  also  syncopal, 
apoplectic,  and  epileptiform  seizures. 

Diagnosis.  The  obvious  signs  of  severe  cardiac  incom- 
j)etence,  in  the  absence  of  primary  valvular  disease,  make 
the  diagnosis  easy  in  the  later  stages,  but  the  condition  may 
well  be  overlooked  at  its  commencement.  Danger  signals 
are  the  appearance  in  an  elderly  man  of  undue  dyspnoea 
on  exertion,  irregularity  of  the  heart's  action  after  slight 
exertion,  shortening  of  the  first  sound,  spacing  of  the  heart 
sounds,  and  an  irregular,  small,  soft  pulse,  possibly  in  a 
thickened  artery. 


238  MEDICAL   DIAGNOSIS 

It  is  not  possible  clinically  to  differentiate  with  certainty 
between  fibroid  and  fatty  hearts.  Poor  circulation  with 
cyanosed  extremities  in  an  obese  individual  who  is  prone 
to  sleep  in  the  daytime,  together  with  absence  of  obvious 
arterial  degeneration,  would  suggest  fatty  rather  than 
fibroid  heart,  provided  that  the  other  signs  and  symptoms 
of  cardiac  degeneration  were  present. 


XI.  SOME  FORMS  OF  CARDIAC  IRREGULARITY. 

In  the  last  few  years  the  work  of  Mackenzie,  Lewis,  and 
others  with  the  polygraph  and  the  electrocardiograph  has 
made  it  possible  to  speak  with  some  certainty  as  to  the 
actual  mechanism  which  causes  irregular  heart-beats.  We 
are  also  enabled  to  estimate  to  a  better  extent  than  before 
the  clinical  significance  of  some  of  the  more  common  irregu- 
larities, and  the  result  is  that  the  prognosis  of  heart  disease 
has  been  placed  altogether  on  a  more  sure  basis  than  was 
formerly  the  case. 

The  Polygraph  is  an  instrument  which  gives  simultaneous 
tracings  of  the  auricular  and  ventricular  beatings,  and  on 
the  same  ribbon  is  a  time  lever  marking  fifths  of  a  second. 
Considerable  practice  is  required  to  interpret  correctly 
the  tracings  of  a  polygraph,  but  most  accurate  information 
can  be  obtained  from  the  instrument  by  one  skilled  in  its  use. 

The  Electrocardiograph  affords  similar  and  even  more 
accurate  information,  but  its  use  is  necessarily  restricted  to 
the  electrical  department  of  large  hospitals. 

In  the  present  work  it  is  not  proposed  to  discuss  further 
the  polygraph  or  the  electrocardiograph,  but  rather  to 
describe  shortly  the  clinical  aspects  of  some  of  the  cardiac 
disorders  which  have  been  elucidated  by  their  means. 

Before  proceeding  to  the  irregularities  of  rhythm  it  is 
necessary  to  refer  briefly  to  the  normal  mechanism  of  the 
heart-beat.  The  heart  beats  as  the  result  of  a  series  of 
rhythmical  impulses  which  arise  in  a  small  mass  of  tissue 
called  the  sino-auricular  node.  This  node  i^  situated  at 
the  end  of  the  sulcus  terminalis  close  to  the  junction  of  the 
superior  vena  cava  and  the  right  auricle.     The  impulses 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   239 

pass  through  the  muscle  of  both  auricles  and  thence  to  the 
auriculo-ventricular  bundle  of  His,  which  runs  from  the 
right  auricle  near  the  coronary  sinus  forwards  and  down- 
wards in  the  inter-ventricular  septum,  to  be  distributed 
throughout  the  muscle  cells  of  each  ventricle.  The  contrac- 
tions of  the  auricular  and  ventricular  chambers  follow  a 
perfectly  regular  and  definite  sequence,  the  wave  of  contrac- 
tion starting  at  the  sino-auricular  node,  spreading  through 
both  auricles  and  thence  down  the  auriculo-ventricular 
bundle  to  the  ventricles. 

Every  auricular  contraction  is  followed,  after  a  definite 
and  constant  interval,  by  a  ventricular  contraction,  and  the 
commencement  of  ventricular  contraction  coincides  approxi- 
mately with  the  termination  of  auricular  contraction. 

The  period  elapsing  between  the  inception  of  auricular 
contraction  and  the  inception  of  ventricular  contraction 
is  called  the  "  As-Vs  "  interval  ;  it  is  an  important  measure- 
ment, as  will  become  apparent  later,  and  can  readily' be 
determined  by  the  polygraph. 

The  ventricle  in  diastole  is  always  ready  to  receive  from 
the  auricle  a  stimulus  to  contract  ;  if,  however,  the  auricle 
sends  a  stimulus  to  the  ventricle  when  the  latter  is  in  systole 
(an  event  M'hich  can  only  occur  in  disease),  the  ventricle 
cannot  respond  and  that  stimulus  is  lost. 

An  important  point  is  the  tendency  for  the  auricle  to 
continue  beating  with  perfect  regularity,  quite  regardless 
of  what  the  ventricle  may  be  doing,  so  long  as  there  is  no 
auricular  disease. 

The  cardiac  nerve  plexuses  ramify  amply  in  the  sino- 
auricular  node,  and  but  for  one  deterrent  factor  the  auricular 
rate  would  be  considerably  more  rapid  than  it  is  ;  the 
deterring  factor  is  the  vagus  nerve,  which  exerts  a  constant 
inhibitory  influence  on  the  frequency  of  the  stimuli  sent  out 
by  the  sino-auricular  node. 

Adopting  the  classification  of  Lewis,  the  following  ir- 
regularities in  cardiac  rhythm  may  now  be  considered 
separately  : — 

(1)  Sinus  irregularity. 

(2)  Heart-Block. 

(3)  Premature  Contractions. 


240  MEDICAL   DIAGNOSIS 

(4)  Simple  Paroxysmal  Tachycardia. 

(5)  Auricular  Flutter. 

(6)  Auricular  Fibrillation. 

(7)  Pulsus  Alternans. 

(1)  Sinus  Irregularity.  In  sinus  irregularity  each  phase 
of  the  cardiac  cycle  occurs  absolutely  normally  ;  the 
As — Vs  interval  is  always  precisely  the  same,  but  the  indi- 
vidual heart-beats  do  not  foUow  each  other  at  identical 
intervals.  Clinically  this  is  perceived  by  pauses  of  unequal 
length  between  the  pulse  as  felt  at  the  wrist  or  at  the 
cardiac  impulse,  though  each  beat  when  it  comes  is  of  similar 
quality  to  its  fellows. 

Sinus  irregularities  are  due  to  vagal  influences  and  are 
often  rhythmical. 

The  following  types  may  be  recognised  : — 

(a)  Tachycardia  the  result  of  large  doses  of  atropine, 

which  paralyses  the  vagus  endings  in  the  heart  and  permits 

of  a  pulse-rate  of  100  to  160  per  minute. 

(6)  Definite  slowing  of  the  heart  is  a  common  manifes- 
tation of  aortic  stenosis,  jaundice,  high  blood  pressure, 

pregnancy,   convalescence   from   specific   infections,    and 

prolonged  muscular  endeavour. 

(c)  Eesjnratory    Influences.     In    children    and    young 

adults  forced  inspiration  quickens  the  rate  of  the  pulse, 

which  again  becomes  slowed  when  the  lungs  empty. 
In  older  people  this  effect  is  not  commonly  obtained. 
In  young  adults  ordinary  respiration  has  no  perceptible 

effect  on  the  pulse-rate,  but  in  children  very  often  there 

are  one  or  two  quite  long  pauses  at  the  end  of  ordinary 

expiration. 

{d)  Periodic    and    wave-like    variations    in    pulse-rate 

lasting  perhaps  twenty  to  thirty  seconds  may  follow  large 

doses  of  digitalis. 

The  diagnosis  of  sinus  irregularities  depends  on  the 
following  points  : — 

(i.)  The  age  of  the  Patient.  Practically  all  irregularities 
in  young  children  (up  to  ten  years)  are  of  this  nature. 

(ii.)  Evidence  of  respiratory  influence  ;  this,  when  present, 
points  conclusively  to  sinus  irregularity. 

(iii.)  The  uniformity  of  the  pulse  waves  and  of  the  cardiac 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM   241 

impulses,  as  well  as  the  correspondence  of  radial  pulse  and 
apex  beat,  are  strong  points  in  favour  of  sinus  irregularity, 
(iv.)  The  disappearance  of  the  irregularity  if  the  pulse-rate 
becomes  raised,  as  by  exercise  or  in  febrile  conditions. 

(2)  Heart-Block.  This  condition  depends  upon  some 
obstruction  to  the  passage  along  the  auriculo-ventricular 
bundle  of  the  impulse  to  contract,  which  normally  passes 
from  the  right  auricle  to  the  ventricles.  Erlanger  has  shown 
that  all  grades  of  heart-block  may  be  produced  experi- 
mentally by  clamping  the  auriculo-ventricular  bundle  at 
different  pressures.  Such  obstruction  may  be  caused  by 
myocardial  intoxication  from  specific  infections,  such  as 
rheumatism,  diphtheria,  influenza,  enteric  fever,  septicaemia 
(of  these  rheumatism  is  undoubtedly  the  most  important), 
or  to  myocardial  degeneration  from  fibrous  replacement,  the 
result  of  syphilis  or  of  arterio-sclerosis  from  any  cause. 

It  is  understood  that  for  heart-block  to  occur  the  lesion 
must  actually  involve  the  auriculo-ventricular  brtndle, 
though,  of  course,  this  is  often  only  a  local  manifestation 
of  a  much  more  widely  diffused  condition.  The  bundle 
may  be  rendered  entirely  functionless,  or  its  conductivity 
may  only  be  impaired  to  a  greater  or  less  extent. 

The  earliest  result  of  an  incomplete  lesion  is  to  hamper 
the  impulses  in  their  jDassage  from  the  auricle  to  the 
ventricle,  and  this  causes  delay  in  their  transmission,  so 
that  there  is  a  prolongation  of  the  As  —  Vs  interval. 

Now  it  must  be  remembered  that  all  the  while  the  auricle 
goes  on  steadily  contracting  at  its  normal  and  regular  rate, 
so  that  as  the  As — Vs  interval  gets  longer  so  does  the  com- 
mencement of  each  auricular  contraction  get  closer  and 
closer  to  the  end  of  the  previous  ventricular  s3^stole,  with 
the  result  that  eventually  an  auricular  stimulus  reaches  the 
ventricle  when  it  is  in  systole  and  so  unable  to  respond  ;  at 
this  juncture  there  is  a  ventricular  silence  or  dropped  beat 
and  the  ventricle  is  enabled  to  rest  before  responding  to  the 
next  auricular  stimulus. 

The  further  fact  has  been  established  that,  as  a  rule, 
the  As — Vs  intervals  lengthen  progressively  up  to  a  point, 
but  that  the  intervals  immediately  preceding  the  ventricular 
silence  shorten  up  again  quite  definitely,  and,  further,  the 

M.D.  16 


242 


MEDICAL  DIAGNOSIS 


K         -2 


c  3  oj  e 


As — Vs  interval  immediately  fol- 
lowing the  silence  is  notably 
shortened.  The  result  of  this  is 
that  the  long  silence  is  rather 
shorter  than  the  length  of  two 
ordinary  pauses,  and  there  is  a 
definite  quickening  of  the  ven- 
tricle just  before  and  just  after 
the  silence. 

As  the  severity  of  the  heart- 
block  increases,  characteristic 
rhythms  are  sometimes  found 
in  which  the  ventricle  is  enabled 
to  respond  to  every  alternate 
auricular  stimulus  (a  2  :  1  heart- 
block)  or  to  every  third  auricu- 
lar stimulus  (a  3  :  1  heart-block), 
etc.  The  effect  of  these  latter 
rhythms  is  to  produce  a  slow 
but  perfectly  regular  pulse  the 
rate  of  which  is  a  definite  frac- 
tion, one-half,  one-third,  or  one- 
quarter,  as  the  case  may  be,  of 
the  auricular  rate,  which  usually 
remains  about  72  per  minute. 

In  complete  heart-block  no 
stimuli  at  all  reach  the  ventricle 
from  the  auricle.  Under  such 
circumstances  the  ventricle  in- 
stitutes a  rhythm  of  its  own 
which  is  perfectly  regular  but 
very  slow,  usually  28  to  30  per 
minute  ;  the  ventricle  and  auricle 
are  now  beating  independently 
of  each  other,  both  quite  regu- 
larly, but  at  widely  different 
rates  (Fig.  45). 

The  Clinical  Diagnosis  of  Heart- 
Block.  It  may  be  quite  impos- 
sible   to    diagnose    heart-block 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM  243 

without  recourse  to  special  graphic  methods  ;  it  may, 
however,  be  suspected  if  attention  is  paid  to  the  foliomng 
points  : — 

(i.)  When  the  heart -block  is  of  such  mild  grade  that  there 
are  no  dropped  beats,  the  widening  of  the  As — Vs  interval 
may  lead  to  audible  recognition  of  the  sound  of  auricular 
systole,  which  becomes  apparent  as  a  reduplication  of  either 
the  first  or  second  cardiac  sound,  according  as  to  whether  the 
auricular  and  ventricular  systoles  are  slightly  or  more 
widely  separated. 

Similarly  in  mitral  stenosis  the  murmur  of  auricular 
sj^stole  may  become  displaced  backwards  till  it  occupies 
early  diastole  and  not  "  pre -systole." 

(ii.)  When  there  is  an  occasional  long  pause  in  the  radial 
pulse  and  examination  of  the  cardiac  impulse  shows  that  these 
pauses  coincide  with  a  ventricular  silence  and  the  pauses  ara 
not  connected  with  the  respiratory  cycle,  it  is  justifiable  to 
diagnose  partial  heart -block,  especially  if  there  is  a 'recog- 
nisable quickening  of  the  pulse-rate  just  before  and  just  after 
the  pause,  so  that  the  pause  is  not  equal  to  two  ordinary 
beats,  though,  even  if  the  pause  is  equal  to  two  ordinary'' 
beats,  heart-block  is  the  probably  explanation. 

(iii.)  When  the  pulse-rate  becomes  suddenly  half  or  one- 
third  its  previous  rate,  heart-block  is  the  probable  cause. 

(iv.)  A  ventricular  rate  of  35  or  less,  especially  when  quite 
regular,  justifies  the  diagnosis  of  complete  heart-block.  In 
such  cases  occasional  first  sounds  are  louder  than  their 
neighbours  owing  to  coincidence  of  auricular  and  ventricular 
systoles,  and  occasional  first  sounds  appear  reduplicated 
when  the  auricular  and  ventricular  systoles  follow  each  other 
very  closely.  Regular  pulsations,  corresponding  to  the  auri- 
cular systoles,  may  be  detected  in  the  jugular  veins,  and  these 
venous  pulsations  wax  and  wane  indejK'ndently  of  respiration. 

(v.)  Large  doses  of  digitalis  and  similar  drugs  may  pro- 
duce heart-block. 

The  clinical  significance  of  heart -block  depends  very  largely 
on  the  condition  of  the  heart  muscle  as  a  whole  and  also  on 
the  soundness  or  otherwise  of  the  valves. 

If  the  damage  is  confined  to  the  auriculo-ventricular 
bundle,  heart-block   seems   little   or  no  bar   to   an   active 

16—2 


244  MEDICAL   DIAGNOSIS 

and  vigorous  existence  ;  neither  is  it  incompatible  with 
longevity. 

Only  too  often,  however,  the  particular  damage  which 
causes  heart-block  is  but  part  of  a  widespread  myocardial 
and  valvular  disease,  and  in  such  cases  the  outlook  is  corre- 
spondingly serious,  but  more  from  the  ordinary  results  of 
heart  failure  than  from  the  heart-block. 

As  a  matter  of  clinical  interest  it  may  be  mentioned  here 
that  unconsciousness  is  the  rule  when  there  is  no  ventricular 
systole  for  from  three  to  seven  seconds,  when  the  heart-beats 
fall  notably  below  twenty  per  minute,  or  when  they  accelerate 
to  300  per  minute,  as  may  very  occasionally  happen  in 
Auricular  Flutter  (vide -p.  249). 

Stokes-Adams  Syndrome.  This  name  is  given  to  a  group  of 
cases  in  which  there  is  a  severe  grade  of  heart-block  asso- 
ciated with  a  certain  definite  train  of  symptoms.  All  cases 
of  Stokes-Adams  syndrome  have  heart-block,  but  all  cases 
of  heart-block  do  not  have  Stokes-Adams  syndrome.  The 
especial  signs  described  are  most  liable  to  occur  when  the 
block  is  practically  complete.    They  consist  of: — 

(i.)  Attacks  of  giddiness  1    t>    i,  i,i      i       u.  t.     i 

\.\  r,  1     ..     1  Probably  due  to  cerebral 

(n.)  Syncopal  attacks    .  .  r 

^   /  _y  .,    ^  .„  ,       ,  anaemia. 

(mi.)  Epileptiform  attacks  j 

(iv.)  Venous  pulsation  in   the   neck,   which   does  not 

synchronise  with  the  cardiac  impulse, 
(v.)    A  ventricular  rate  of  35  or  less. 

In  addition  to  the  above,  paroxysmal  dyspnoea  or  cardiac 
asthma  may  be  met  with,  and  (in  the  older  patients)  there  is 
likely  to  be  arterial  thickening. 

The  full  Stokes-Adams  syndrome  is  most  often  seen  in  men 
over  50  years  of  age. 

(3)  Premature  Contractions  or  Extrasystoles.  These  are  con- 
tractions occurring  before  the  proper  rhythmical  time  which 
originate  abruptly  in  some  other  spot,  either  auricular  or 
ventricular,  than  the  sino -auricular  node,  and  which 
do  not  tend  to  initiate  a  definite  rhythmical  series  of 
contractions. 

Premature  contractions  may  be  either  ventricular  or 
auricular  in  origin,  and  are  the  usual  cause  of  "  intermittent 
pulse." 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   245 

(a)  A  Ventricular  Premature  Contraction  occurs  after 
an  unusually  short  pause  ;  it  is  usually  weak,  does  not 
reach  the  wrist,  and  often  fails  to  raise  the  aortic  and 
pulmonary  valves  sufficiently  for  there  to  be  a  second 
sound.  Nevertheless,  the  ventricle  is  in  systole  when 
the  next  auricular  impulse  reaches  it  ;  consequently  it  is 
unable  to  respond  and  there  is  a  long  pause.  The  ven- 
tricle takes  up  the  next  auricular  impulse  in  precisely  the 
manner  and  at  precisely  the  time  as  it  would  if  there  had 
been  no  disturbance. 

The  time  from  the  commencement  of  the  ventricular 
systole  before  the  premature  contraction  to  the  commence- 
ment of  the  ventricular  systole  next  after  the  premature 


Fig.  46. — Ventricular  tracing  to  show  Premature  Contractions  marked  X. 

Note  that  the  interval  A  B  =  the  interval  B  C.  and  likewise  C  D  =  DE, 

which  suggests  that  the  extrasystolcs  are  ventricular  in  origin. 

contraction  is  exactly  double  the  ordinarj'^  cardiac  cycle 
— that  is  to  say,  there  has  been  interpolated  a  premature 
and  ineffective  ventricular  contraction  instead  of  a 
normal  one,  and  beyond  that  nothing  is  altered. 

(6)  In  Auricular  Premature  Contraction  the  auricle 
contracts  before  its  time,  and  this  premature  contraction 
is  followed  by  a  ventricular  response  in  precisely  the 
same  manner  as  in  a  normal  auricular  contraction.  Both 
chambers  are  momentarily  out  of  gear  with  the  normal 
sino-auricular  rhythm. 

The  period  between  the  commencement  of  the  prema- 
ture systole  and  the  commencement  of  the  next  or  normal 
systole  is  longer  than  the  ordinary  inter -systolic  interval, 
but  the  interval  between  tlie  commencement  of  tlie  normal 
systole  before  the  premature  contraction  and  the  first 
normal  systole  subsequent  to  this  is  riot  quite  so  long  as 


24C  MEDICAL   DIAGNOSIS 

two  ordinary  cardiac  cycles,  as  is  the  case  in  premature 

ventricular  contractions. 

By  definition  it  is  agreed  that  the  premature  contractions 
are  the  result  of  stimuli  originating  elsewhere  in  the  heart 
muscle  than  in  the  sino-auricular  node.  The  cause  of  such 
stimuli  is  not  very  certain  ;  nevertheless,  it  has  been  shown 
that  age  is  an  important  factor,  since  premature  contractions 
are  most  frequent  between  the  ages  of  50  and  70  and  are 
hardly  ever  found  before  the  age  of  10  years.  Further, 
nearly  60  per  cent,  of  these  cases  are  associated  with  grave 
cardiac  lesions  either  valvular  or  myocardial. 

Over-indulgence  in  tobacco  is  a  fairly  frequent  temporary 
cause  of  these  extrasystoles,  especially  in  young  men.  At 
the  same  time  a  large  group  is  left  in  which,  beyond  the 
occurrence  of  premature  contractions,  the  patient  has  no 
demonstrable  lesion :  in  such  it  does  not  seem  justifiable  to 
attach  much  importance  to  the  phenomenon. 

Again,  when  there  is  obvious  cardiac  disease  as  well  as 
premature  contractions,  the  prognosis  is  necessarily  very 
guarded,  quite  apart  from  the  latter. 

From  these  considerations  it  may  be  argued  that  prema- 
ture contractions  'per  se  are  of  little  or  no  significance, 
though  probably  adding  somewhat  to  the  gravity  of  a  case 
with  obvious  cardiac  disease.  On  the  other  hand,  premature 
contractions  are  necessarily  evidence  of  some  pathological 
process,  and,  as  such,  are  always  worthy  of  attention  in  the 
direction  of  periodical  re-examination,  for  they  may  be  the 
first  stage  in  a  progressive  lesion  in  so  far  as  there  is  a  common 
pathological  basis  for  premature  contractions  and  the  more 
serious  irregularities,  such  as  paroxj^smal  tachycardia, 
auricular  flutter,  and  auricular  fibrillation. 

The     Clinical    Diagnosis     of    Premature     Contractions. 

(i.)  They  may  be  induced  by  the  digitalis  group  of  drugs. 

(ii.)  They  are  rare  when  the  pulse-rate  is  over  100  per 
minute,  and  they  are  temporarily  abolished  by  anything 
(e.g.,  exercise  or  fever)  which  raises  the  pulse-rate  to  this 
frequency  or  over. 

(iii.)  They  may  be  induced  by  forced  holding  of  the 
breath. 

(iv.)  They  tend  to  disappear  when  the  patient  lies  down. 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM   247 

(v.)  A  long  pause  in  the  radial  pulse,  during  wliioli  a 
ventricular  systole  can  be  felt  at  the  cardiac  impulse,  is 
suggestive  of  a  premature  contraction  of  insufficient  force 
to  raise  the  aortic  valves. 

The  auscultatory  sign  of  this  is  an  apparent  grouping 
of  three  sounds  at  the  time  of  the  extrasystole,  these  being 
the  first  and  second  sounds  of  a  normal  heart-beat  closely 
followed  by  the  extra  contraction. 

(vi.)  If  the  contraction  is  strong  enough  to  send  blood 
into  the  arteries,  there  is  an  extra  first  and  second  sound, 
so  that  the  heart  sounds  at  the  moment  appear  grouped  in 
fours.  In  this  variety  there  is  not  a  complete  pause  in  the 
radial  pulse,  but  there  is  instead  a  hurried  and  feeble  beat 
(the  premature  contraction)  followed  by  a  rather  longer 
pause  than  usual. 

(vii.)  If  the  extrasystoles  are  sufficiently  numerous  to 
alternate  with  the  ordinary  rhythmical  beats,  the  heart 
sounds  are  arranged  constantly  in  "  groups  of  tfiree," 
provided  that  the  aortic  valves  are  not  raised  by  the  prema- 
ture contraction,  and  the  heart-rate  is  double  the  radial 
pulse-rate. 

If  the  aortic  valves  are  raised,  the  radial  pulse  is  in 
pairs,  one  strong  and  one  feeble,  and  the  heart-beats  are  in 
fours. 

This  last  condition  is  not  the  same  as  pulsus  alternans, 
in  which  the  interval  between  the  beats  is  practically  equal. 

(viii.)  Apart  from  a  pulse  tracing  it  may  be  impossible 
to  distinguish  between  auricular  and  ventricular  premature 
contraction,  neither  is  this  differentiation  of  importance. 
In  the  former  there  is  disturbance  of  the  normal  sino- 
auricular  rhythm,  in  the  latter  there  is  not.  This  may 
sometimes  be  appreciated  by  estimating  with  the  finger  or 
the  ear  whether  the  area  of  disturbance — that  is  to  say, 
the  interval  between  the  commencement  of  the  systoles 
next  before  and  next  after  the  extra  one — is  equal  to  or 
less  than  two  ordinary  cardiac  cycles.  In  the  former  case 
the  disturbance  is  ventricular,  in  the  latter  it  is  auricular. 
Other  diagnostic  features  may  be  : — («)  If  the  disturbance 
is  ventricular,  the  premature  contraction  may,  and  is 
indeed  likely  to,  coincide  with  the  next  normal  auricular 


248  MEDICAL   DIAGNOSIS 

systole  ;  the  result  of  this  is  to  force  the  blood  into  the 
veins  of  the  neck  with  a  jerk  that  can  easily  be  recognised. 
(h)  The  same  coincidence  of  auricular  and  ventricular 
systoles  tends  sometimes  to  exaggerate  that  particular  first 
sound. 

(ix.)  Aortic  murmurs  in  premature  contractions  depend 
on  whether  the  aortic  valves  are  raised  or  not. 

IVIitral  systolic  murmurs  are  present  with  the  extrasy stole. 
Mitral  presystolic  murmurs  are,  of  course,  absent  when  the 
premature  contraction  is  ventricular,  and  usually  also  when 
it  is  auricular,  probably  because  the  extra  contraction  is 
too  feeble  to  generate  a  murmur. 

(x.)  Premature  contractions  are  often  unnoticed  by  the 
patient,  but  he  may  complain  of  palpitations,  of  a  sense  of 
oppression  during  the  long  pause,  or  of  feeling  his  heart 
miss  a  beat. 

(4)  Simple  Paroxysmal  Tachycardia.  By  this  is  meant 
the  periodical  domination  of  the  normal  sino-auricular 
rhythm  by  a  series  of  impulses  which  originate  in  some  other 
part  of  the  heart  muscle,  usually  in  the  auricle,  but  some- 
times in  the  ventricle.  These  impulses  are  fired  off  from 
110  to  200  times  a  minute,  or  more  commonly  140  to  190. 
The  condition  is  comparable  to  a  series  of  consecutive 
premature  contractions  occurring  so  rapidly  as  to  block 
all  the  normai  sino-auricular  impulses  for  the  time  being. 

When  the  impulses  originate  in  the  ventricle  it  is  to  be 
presumed  that  the  stimulus  spreads  in  a  retrograde  manner 
to  the  auricles,  which  then  occupy  the  second  stage  of  the 
cardiac  cycle  with  their  systoles. 

When  the  paroxysm  terminates  there  is  a  longer  pause 
than  there  is  between  two  normal  beats,  just  as  after  a 
single  premature  contraction,  but  the  intervals  between 
the  successive  beats  of  a  paroxysm  are  of  equal  length, 
which  indicates  a  single  focus  of  elaboration  for  the  abnormal 
stimuli. 

Nearly  half  these  cases  have  obvious  myocardial  degenera- 
tion or  mitral  disease,  and  a  certain  number  have  arterio- 
sclerosis or  renal  disease,  while  it  seems  certain  that,  whether 
or  not  there  are  signs  or  symptoms,  all  these  cases  depend 
upon  a  definite  myocardial  change.     It  will  be  noted  that 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   249 

tachycardia  from  increase  of  activity  in  the  sino-auricular 
node  is  a  totally  distinct  condition. 

Simple  paroxysmal  tachycardia  is  met  with  at  an}^  age 
after  10  years,  it  is  perhaps  most  frequent  between  20  and  30, 
and  occurs  more  often  in  men  than  women. 

Individual  paroxysms  may  last  from  a  few  seconds  to 
uj:) wards  of  tMo  Aveeks. 

The  diagnosis  depends  on  the  following  points  : — 

(i.)  The  abrupt  onset  and  equally  abrupt  termination  of 
an  attack. 

(ii.)  The  rate  of  heart-beat.  Any  adult  heart  with  a  rate 
of  160  or  more  is  almost  certainly  deriving  its  impulses  from 
an  abnormal  site. 

(iii.)  The  absolute  lack  of  influence  of  change  of  posture 
or  respiration  on  the  rate  of  the  heart -beats  (this  helps  to 
exclude  sinus  tachycardia). 

(iv.)  The  fact  that  paroxysms  may  be  ehcited  by  emotional 
factors,  dyspepsia,  and  such  trivial  things  as  the  adoption  of 
certain  postures. 

The  symptoms  vary  greatly,  and  depend  to  a  large 
extent  on  the  duration  of  the  attack.  Palpitation,  exhaus- 
tion, coldness,  and  sweating  are  commonly  noted  ;  anginal 
pain  is  not  rare,  and  in  more  serious  cases  an  increasing  area 
of  cardiac  dulness  is  accompanied  by  dyspnoea,  with  cyanosis, 
venous  engorgement,  oedema  of  the  feet,  pulsating  liver, 
and  pulmonary  oedema,  which  may  cause  great  anxiety  and 
even  terminate  fatally. 

Even  when  the  patient  is  apparently  in  extremis  the 
attack  may  terminate  in  the  usual  abrupt  manner,  and 
recovery  is  then  peculiarly  rapid. 

Such  conditions  as  alcoholism  and  Graves'  disease, 
which  cause  tachycardia,  can  usually  be  excluded  by  their 
appropriate  physical  signs,  by  the  lack  of  the  paroxysmal 
clement,  and  by  the  reaction  of  the  pulse-rate  in  these 
patients  to  sedatives  and  recumbency. 

(5)  Auricular  Flutter.  This  can  be  regarded  as  a  develop- 
ment of  simple  paroxysmal  tachycardia  when  the  new 
rliythm  has  completely  dominated  the  situation  but  wherein 
the  auricular  rate  is  very  much  more  rapid  than  in 
paroxysmal  tachycardia. 


250  MEDICAL   DIAGNOSIS 

The  rate  of  the  auricular  beat  has  been  settled  arbitrarily 
(for  clinical  purposes)  as  from  200  to  350  per  minute.  The 
reason  for  this  arbitrary  distinction  lies  in  the  fact  that 
after  the  rate  of  200  per  minute  is  reached  the  ventricle  does 
not  get  sufficient  length  of  latent  periods  and  becomes 
unable  to  keep  up  ;  the  result  is  heart-block,  which  is 
practically  always  present  in  cases  of  auricular  flutter. 

When  this  perverse  rhythm  is  once  established  the 
tendency  is  for  it  to  continue  for  many  months, 
though  sometimes  paroxysmal  auricular  flutter  may  be 
found. 

A  common  type  of  case  is  for  the  auricle  to  beat  say 
300  to  320  times  per  minute  and  the  ventricle  at  half  this 
rate  (2  :  1  heart-block).  Less  commonly  a  3:1  or  4:1 
heart -block,  is  met  with,  and  sometimes  complete  heart- 
block  may  be  found  in  cases  of  flutter. 

Except  for  the  rate  of  the  auricle,  all  that  was  said  in 
the  section  on  "  Heart-Block  "  applies  to  flutter  also,  and 
a  very  striking  point  is  the  absolute  regularity  of  the  auri- 
cular contractions  and  their  frequency  throughout  weeks 
and  weeks.  In  a  like  manner,  since  the  ventricular  contrac- 
tions (even  when  not  in  simple  ratio  to  the  auricular  contrac- 
tions) appear  in  definite  cycles  at  stated  intervals,  the 
frequency  of  the  cardiac  impulses  has  the  same  striking 
uniformity  for  the  same  patient. 

Auricular  flutter  must  be  regarded  as  due  to  myocardial 
degeneration  ;  it  is  more  common  in  men  than  women  and 
is  most  often  found  between  the  ages  of  50  and  70  years. 

It  occasionally  happens  that  for  a  few  moments  the 
ventricle  picks  up  each  of  the  auricular  contractions  ;  this 
induces  unconsciousness  if  the  rate  approaches  300  per 
minute,  and  is  speedily  fatal  if  it  persists. 

The  diagnosis  of  auricular  flutter  cannot  always  be  made 
without  the  polygraph  or  electrocardiograph  ;  especially 
is  this  the  case  when  the  ventricular  rate  is  slow  and  regular, 
for,  unless  it  is  possible  to  perceive  some  venous  fluttering 
in  the  neck,  there  is  no  way  of  appreciating  what  is  happening 
in  the  auricles.  Nevertheless,  a  slow  ventricle  is  the  exception 
rather  than  the  rule,  so  that  auricular  flutter  may  often  be 
suspected  under  the  following  circumstances  : — 


DISEASES  OF  THE  CAKDIO -VASCULAR  SYSTEM  251 

(i.)  A  regular  and  persistent  pulse  of  130  to  160  per  minute 
in  an  elderly  man,  especially  if  a  history  of  previous  attacks 
of  tachycardia  can  be  elicited. 

(ii.)  The  constant  repetition  of  the  same  high  pulse-rate 
throughout  weeks  and  months. 

(iii.)  No  alteration  in  rate  with  altered  position,  rest  or 
exercise. 

(iv.)  Occasional  brief  crises,  possibly  with  loss  of  con- 
sciousness, due  to  a  very  transient  increase  of  ventricular 
rate  to  that  of  the  auiicle. 


vv    y    <t    »    »    >    i>M<»»'fy    n 


Fig.  47. — Polygraph  tracing  to  show  Auricular  Flutter  combined  with  a  2  :  1 
Heart-block.  The  upper  tracing  shows  the  auricular  wave ;  the  lower 
tracing  is  the  radial  pulse. 

Note  the  rapidity  and  regularity  of  the  auricular  systoles,  also  that  the  auricle 
beats  twice  for  each  ventricular  contraction.  The  topmost  line  is  a  time 
record  showing  fifths  of  a  second. 

(v.)  The  fact  that  digitalis  both  slows  the  pulse  by  further 
blocking  the  auricular  impulses  and  also  makes  it  irregular. 

The  symptoms  of  auricular  flutter  are  strikingly  few. 
When  the  flutter  is  paroxysmal  the  symptoms  are  those  of 
flaroxysmal  tachycardia  ;  when,  as  is  usually  the  case,  the 
putter  is  well  established  and  a  well-defined  heart-block  is 
present,  even  though  the  ventricular  rate  is  160  per  minute, 
the  symptoms  are  often  only  those  of  slight  myocardial 
degeneration — that  is  to  say,  easy  fatigue  and  dyspnoea  on 
exertion. 

Of  course,  if  the  heart  muscle  is  profoundly  altered,  more 
urgent  congestive  symptoms  are  likely  to  be  present. 

(6)  Auricular  Fibrillation.  In  this  condition  the  normal 
sino-auricular  rliythm  is  replaced  by  impulses  arising  at 
very  many  different  points  in  the  auricular  muscle.     Any 


252  MEDICAL   DIAGNOSIS 

orderly  auricular  contraction  becomes  impossible,  since 
many  different  small  parts  of  the  auricle  are  constantly 
contracting  independently.  An  auricle  seen  in  a  state  of 
fibrillation  appears  to  be  distended  in  diastole  ;  closer 
examination  shows  that  it  is  "  twittering  "  all  over,  but  each 
contraction  is  so  minute  and  so  local  that  there  is  no  result 
on  the  auricle  as  a  whole. 

The  ventricle  picks  up  as  many  of  these  auricular  impulses 
as  it  can,  but  does  so  in  a  most  haphazard  manner  ;  conse- 
quently the  pulse  becomes  both  rapid  and  extremely 
irregular. 

It  has  been  suggested  that  the  nature  of  the  changes  in 
the  auricular  musculature  which  cause  fibrillation  is  akin 
to  that  which  causes  a  single  premature  auricular  contrac- 
tion, with  the  addition  that  in  the  latter  there  are  multiple 
pathological  foci  and  in  the  former  only  one. 

The  number  of  effective  impulses  reaching  the  ventricle 
seems  to  vary  with  the  efficiency  of  the  auriculo-ventricular 
bundle  ;  if  this  is  quite  healthy  the  ventricular  rate 
approaches  its  potential  maximum  of  200  per  minute  : 
conversely  heart-block  is  not  incompatible  with  auricular 
fibrillation.  The  most  usual  rate  is  between  90  and  140  per 
minute. 

Auricular  fibrillation  is  considerably  more  frequent  in 
men  than  in  women  and  the  etiological  influence  of  rheuma- 
tism can  be  traced  in  over  60  per  cent,  of  cases.  As  would 
be  expected,  mitral  stenosis  is  the  lesion  par  excellence  to 
be  associated  with  fibrillation,  and  this  connection  has  been 
traced  in  slightly  more  than  50  per  cent,  of  cases. 

Considering  that,  according  to  Lewis,  more  than  60  per 
cent,  of  all  cases  of  "  heart  failure  "  admitted  into  a  hospital 
can  be  shown  to  have  auricular  fibrillation,  it  is  important 
to  recognise  the  clinical  features  of  this  condition. 

Diagnosis.  Apart  from  the  polygraph  or  electrocardio- 
graph, the  diagnosis  of  auricular  fibrillation  depends  on  the 
following  considerations  : — 

(i.)  The  extreme  irregularity  of  the  heart's  action ;  and, 
since  many  beats  may  fail  to  reach  the  wrist,  it  is  advisable 
to  examine  the  cardiac  impulse.  No  two  beats  are  alike, 
no  series  of  beats  can  be  said  to  resemble  any  other  series, 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM   253 

no  two  pauses  are  the  same  length,  and  the  force  of  the 
impulse  bears  no  apparent  relation  to  the  length  of  preceding 
pause.  Clinically  the  key  to  the  diagnosis  of  auricular 
fibrillation  is  the  very  characteristic  disorderhj  rhythm. 

(ii.)  The  rate  of  the  heart-beats  is  from  100  to  160  in  the 
most  typical  cases.  When  the  rate  is  slower  the  irregularity 
requires  more  care  in  its  detection,  but,  if  suspected,  should 
be  discovered. 

(iii.)  Since  many  contractions  are  ineffective,  the  heart 
sounds  and  murmurs  may  present  some  of  the  features  of 
premature  ventricular  contraction  (p.  245). 

(iv.)  In  mitral  stenosis  the  rough  presystolic  murmur 
disappears  when  fibrillation  sets  in,  but  instead  of  this  a 
softer   diastolic   murmur   appears   early  in   diastole.     This 


Fig.  48. — Pulse  tracing  to  show  the  characteristic  disordorlj  rhjiihrn  of 
Auricular  Fibrillation. 

murmur  starts  just  after  the  second  sound,  but  does  not 
accompany  this  ;  the  more  rapidly  the  heart  is  beating 
the  more  of  the  diastole  is  occupied  by  the  murmur.  With 
a  paralysed  auricle  the  rate  of  flow  from  auricle  to  ven- 
tricle is  greatest  at  the  commencement  of  ventricular 
diastole. 

(v.)  Exertion  increases  the  irregularity  in  auricular 
fibrillation  in  contrast  to  its  effect  in  premature  contractions 
and  partial  heart-block. 

(vi.)  Irregularity  due  to  fibrillation  persists  as  a  rule  until 
death  takes  place. 

The  symptoms  of  Auricular  fibrillation  are  not  character- 
istic, being  practically  those  of  myocardial  degeneration. 

With  regard  to  prognosis,  it  may  be  said  that  an  irregular 
pulse-rate  of  more  than  120  is  of  grave  significance  and  that 
tlic  greater  the  frequency  the  graver  the  prognosis  ;    this  is 


254  MEDICAL   DIAGNOSIS 

of  especial  importance,  in  view  of  the  fact  that  adequate 
digitahs  administration  is  capable  of  reducing  the  pulse-rate 
very  markedly  in  fibrillation  cases  through  blocking  many  of 
the  impulses  from  the  auricle  and  so  resting  the  ventricle, 
though  it  does  not  commonly  cure  the  fibrillation. 

The  ventricle  may  undoubtedly  go  into  a  state  of  fibrilla- 
tion, in  which  case  death  rapidly  takes  place. 

It  is  probable  that  many  cases  of  sudden  death  in  myo- 
cardial fibrosis  are  due  to  ventricular  fibrillation,  and  it  is 
the  immediate  cause  of  death  in  lightning  stroke  and 
electrocution. 

(7)  Pulsus  Alternans.  By  this  is  meant  a  perfectly- 
spaced  pulse,  but  one  in  which  the  strength  of  the  ventricular 
contractions  alternates,  a  powerful  systole  being  followed 
by  a  weak  one. 

Pulsus  alternans  may  occur  when  the  heart  is  acting  very 
rapidly,  as  in  paroxysmal  tachycardia  ;  it  is  not  then  of 
special  significance  :  it  is,  however,  a  sign  of  the  greatest 
import  when  occurring  in  hearts  of  moderate  rate,  and 
indicates  definitely  that  the  heart  is  emphatically  not 
equal  to  the  work  it  is  called  upon  to  perform. 

As  would  be  expected,  it  is  most  often  met  with  in  cases  of 
fibroid  heart,  arterio-sclerosis,  etc.,  but  it  may  occur  in  the 
course  of  the  specific  infections,  sucli  as  pneumonia,  when  a 
fatal  issue  can  be  apprehended. 

The  diagnosis  of  pulsus  alternans  is  usualty  impossible 
apart  from  graphic  methods  (an  ordinary  sphygmographic 
tracing  shows  it  very  well)  ;  it  may  be  appreciated  by  the 
finger,  but  will  more  often  be  overlooked,  since  the  difference 
in  the  vigour  of  the  contractions  is  not  excessive. 

Pulsus  alternans  may  not  be  constant  and  each  cycle  of 
alternation  is  often  initiated  by  a  premature  contraction, 
and,  since  the  prognostic  value  of  alternations  is  very  high 
(though  unfortunately  in  a  bad  sense),  it  is  especially  neces- 
sary to  examine  for  this  condition  any  elderly  person  with 
high  blood  pressure,  renal  disease,  fibroid  heart,  etc..  who 
is  also  liable  to  premature  contractions. 

Pulsus  alternans  must  not  be  mistaken  for — 

(i.)  Dicrotic  Pulse.     In  this  the  apparent  radial  pulse 

rate  is  double  that  of  the  apex  beat. 


DISEASES  OF  THE  CARDIO -VASCULAR  SYSTEM    255 

(ii.)  Alternaiing  Premature  Contractions  {vide  p.  247). 
In  this  the  smaller  beat  is  followed  by  a  definitely  longer 
pause  than  the  more  forcible  beat.  In  pulsus  alternans 
the  spaces  between  the  beats  are  practically  equal,  though 
if  very  accurate  measurements  be  taken  (as  with  a  very 
quickly-moving  paper),  it  will  be  found  that  the  smaller 
beat  is  followed  by  a  slightly  shorter  pause  than  the  more 
forcible  one. 

In  any  case  of  Pulsus  Alternans  the  outlook  is  grave  ; 
when,  however,  the  alternations  are  persistent,  it  is  not  too 
much  to  say  that  the  prospects  of  life  may  be  reckoned  in 
months  or  weeks  rather  than  years. 


Fig.  49. — Polygraph  tracing  to  show  Pulsus  Alternans. 
Xote  the  regular  spacing  of  the  beats  despite  their  unequal  force. 


XII.  CONGENITAL  HEART  DISEASE. 

This  may  be  produced  by  foetal  endocarditis  or  by 
imperfect  development.  In  the  latter  group  especially  there 
are  many  possible  varieties  which  are  not  compatible  with 
life.  The  most  common  abnormality  is  a  patent  foramen 
ovale.  This  is  unlikely  to  produce  either  signs  or  symptoms 
and  is  therefore  of  but  little  or  no  pathological  significance 
when  occurring  as  an  isolated  lesion.  It  is,  however,  very 
likely  to  be  met  with  in  combination  with  other  abnor- 
malities. 

The  following  are  the  more  usual  congenital  heart  lesions 
and  the  murmurs  accompanying  them  : — 

(i.)  Patent  Inter -ventricular  Septum.  Tlie  murmur  is  very 
loud  and  rough,  systolic  in  time,  widely  distributed,  but  ot 


256  MEDICAL   DIAGNOSIS 

maximum  intensity  in  the  third  and  fourth  spaces  to  the 
left  of  the  sternum.     There  is  no  thrill. 

(ii.)  Pulmonary  Stenosis.  A  loud,  rough  systolic  murmur, 
widely  distributed,  but  of  maximum  intensity  in  the  third 
left  space  1  inch  from  the  sternum.  There  is  in  addition  a 
systolic  thrill  over  the  pulmonary  area. 

Pulmonary  stenosis  and  patency  of  the  interventricular 
septum  are  often  concomitant  affections. 

(iii.)  Patent  Ductus  Arteriosus.  A  persistent  loud  murmur 
running  all  through  the  cardiac  cycle,  increasing  through 
systole  and  waning  through  diastole,  best  heard  in  the  third 
left  space  close  to  the  sternum.  There  is  no  thrill  as  a 
rule. 

(iv.)  Congenital  lesions  of  the  aortic,  mitral,  and  tricuspid 
valves  are  relatively  rare  and  present  the  same  signs  as  do 
acquired  lesions  of  the  same  valves. 

The  symptoms  of  congenital  heart  disease  are  fairly 
constant  : — 

{a)  Cyanosis. 

(6)  Clubbing  of  the  fingers  and  toes. 

(c)  Dyspnoea,  either  continuous  or  paroxysmal. 

id)  Convulsive  seizures. 

The  cyanosis  is  very  striking  when  present,  but  it  is  not 
always  to  be  demonstrated.  In  those  cases  in  which  there 
is  cyanosis  there  is  an  increased  number  of  red  cells,  an 
increase  of  hremoglobin,  and  an  increased  specific  gravity 
of  the  blood.  This  increased  viscosity  is  possibly  one  factor 
in  the  production  of  the  cyanosis,  another  factor  being 
the  necessarily  poor  pulmonary  circulation  in  pulmonary 
stenosis. 

Congenital  heart  disease  is  likely  to  be  associated  with 
other  congenital  abnormalities,  both  physical  and  mental, 
and  also  with  malnutrition,  dwarfed  stature,  and  imperfect 
growth. 

The  diagnosis  of  congenital  heart  disease  as  a  whole  does 
not  as  a  rule  present  any  difficulty,  but  it  may  be  impossible 
to  distinguish  between  congenital  lesions  and  hsemic  murmurs 
in  young  children  if  there  is  no  cyanosis,  and  it  is  often 
impossible  to  be  dogmatic  on  the  variety  of  congenital  lesion 
that  may  be  present. 


DISEASES  OF  THE  CARDIO- VASCULAR  SYSTEM   257 

XIII.  ANGINA    PECTORIS. 

The  pathology  of  the  condition  is  still  obscure ;  chnically 
it  presents  a  definite  symptom  complex.  In  the  majority 
of  cases  which  have  been  examined  post  mortem,  coronary 
artery  disease  has  been  revealed  with  coincident  fibrosis 
or  fatty  degeneration  ;  in  other  cases  aortic  valve  lesions 
(stenosis  or  regurgitation)  have  been  present,  and  in  others 
acute  inflammatory  affections,  or  possibly  aneurysm,  of  the 
first  part  of  the  aorta  ;  while  in  a  very  few  cases  careful 
search  has  shown  no  lesion  at  all. 

The  great  majority  of  sufferers  are  men  of  advanced  years. 
Heredity,  gout,  and  high  arterial  tension  appear  to  be  of 
etiological  significance. 

Each  attack  is  characterised  by  sudden  acute  pain  in 
the  prsecordial  region,  often  radiating  up  into  the  leftside  of 
the  neck  and  down  the  inner  side  of  the  left  arm  along  the 
course  of  the  intercosto-humeral  nerve,  or  sometimes  >along 
the  ulnar  nerve.  The  right  side  may  occasionally  be 
implicated. 

The  patient  is  usually  livid,  anxious-looking,  and  covered 
with  a  clammy  perspiration  ;  at  the  same  time  he  has  a 
strong  sensation  of  impending  death. 

The  pulse  is  irregular,  small  and  weak,  and  the  arteries 
are  often  in  a  condition  of  tonic  spasm. 

Each  attack  lasts  from  a  few  seconds  to  a  few  minutes, 
or  may  recur  in  waves  for  several  hours,  and  while  it 
lasts  the  patient  leans  forward  scarcely  daring  to  breathe 
and  supported  by  any  convenient  article.  There  is  a 
copious  eructation  of  wind  at  the  close  of  a  paroxysm, 
and  sometimes  a  large  quantity  of  pale  urine  is  voided. 
The  first  attack  is  generally  excited  by  exercise.  Gradually 
the  attacks  become  more  and  more  frequent  and  are  excited 
by  increasingly  trivial  causes  (sometimes,  indeed,  there  is 
no  apparent  cause  at  all),  such  as  indigestion,  chill,  or  sudden 
movement. 

The  fact  that  true  angina  is  very  rare  in  women  should 
help  to  ditferontiate  it  from  attacks  of  praicordial  pain  and 
palpitations,  which  are  so  common  in  women  round  about 
the   chmactoric    and   those  who  are  sufferers  from  atonic 

M.D.  17 


258  MEDICAL  DIAGNOSIS 

dyspepsia  and  neurasthenia,  espscially  if  it  is  remembered 
tliat  the  first  attack  nearly  always  occurs  after  exercise 
and  that  the  sense  of  impending  death  is  a  constant  feature. 
The  combination  of  a  dilated  stomach  and  a  persistently 
high  arterial  tension  may  closely  simulate  true  angina, 
and  may  well  be  associated  with  a  fatal  syncope.  A  careful 
inquiry  into  the  precise  nature  of  the  attacks  of  pain  and 
the  mode  of  origin  of  the  initial  attacks  will  usually  suffice 
to  prove  the  absence  of  angina  pectoris. 

XIV.  AFFECTIONS  OF  THE  PERICARDIUM. 

Affections  of  the  pericardium  will  be  considered  under 
three  headings  :  (i.)  Acute  Fibrinous  Pericarditis. 

(ii.)  Suppurative  Pericarditis. 

(iii.)  Adherent  Pericardium. 

(i.)  Acute  Fibrinous  Pericarditis.  When  this  occurs  in 
childhood,  it  is  likely  to  be  due  to  rheumatism,  or  possibly 
scarlet  fever  or  even  enteric  fever  ;  in  older  people  gout, 
nephritis,  or  tuberculosis,  are  more  likely  causes. 

The  inflammation  is  accompanied  by  the  formation  of 
more  or  less  sero-fibrinous  effusion,  which  resolves  satis- 
factorily in  the  majority  of  cases. 

Symptoms.  Owing  to  the  extensive  involvement  of  the 
myocardium  in  the  inflammatory  process  the  symptoms 
will  include  those  of  cardiac  dilatation — that  is  to  say, 
dyspnoea,  an  anxious  expression,  and  a  rapid,  feeble  pulse. 
Additional  symptoms  may  be — ■ 

Pyrexia.     This  is  an  almost  constant  phenomenon. 

Pain.  Prsecordial  pain  is  common,  but  in  young 
children  it  is  often  absent. 

Dyaphagia,  from  irritation  of  the  oesophagus. 

Cough,  from  pressure  on  the  trachea. 

Vomiting  is  a  symptom  of  evil  prognosis. 

Deliriurn  is  common. 

The  Physical  Signs: — 

(1.)  Before  there  is  much  effusion^ 

{a)  An  increase  in  the  lateral  extent  of  the  cardiac 

dulness  due  to  dilatation. 

{b)  A   Friction   Rub.     This  is   a  superficial  scratchy, 


DISEASES  OF  THE  CARDIOVASCULAR  SYSTEM  259 

continuous  to-and-fro  rubbing  sound,  not  conducted  in 
any  particular  direction  and  often  modified  by  pressure 
with  the  stethoscope.  It  is  first  heard  at  the  base  in  the 
majority  of  cases  ;  then  it  can  be  detected  at  the  apex 
and  down  the  margins  of  the  sternum.  In  a  few  cases  it 
may  only  be  audible  during  systole,  and  sometimes  it  is 
palpable  as  friction  fremitus.  As  effusion  develops  the  rub 
disappears,  often  to  reappear  as  the  effusion  is  absorbed. 
(2.)  When  there  is  considerable  effusion  : — 

(a)  In  cases  that  have  been  watched  from  their  com- 
mencement the  disappearance  of  the  rub  is  the  fijst 
evidence  that  there  may  be  effusion.  It  must  be  remem- 
bered, however,  that  the  rub  will  disappear  from  adhesion 
between  the  visceral  and  parietal  layers  of  the  pericardium, 
and  also  that  the  rub  may  continue  to  be  audible  at  the 
base  when  there  is  a  large  effusion  at  the  back  of  the 
pericardium. 

(6)  An  increase  of  the  already  great  area  of  cardiac 
dulness  and  an  alteration  in  its  shape.  When  the  increase 
is  entirely  due  to  dilatation,  the  outline  is  more  or  less 
rounded  ;  when  there  is  much  effusion,  the  outline  becomes 
triangular,  with  the  base  of  the  triangle  downwards. 
Important  points  are  an  increase  in  dulness  upwards  and 
oblileration  of  the  cardio-hepatic  angle. 

(c)  Muffling  of  the  Heart  Sounds.  This  is  often  absent, 
since  there  is  a  tendency  for  the  heart  to  float  up  against 
the  chest  wall. 

{d)  Displacement  upwards  and  a  little  outwards  of  the 
cardiac  impulse.  This  sign,  again,  is  by  no  means 
coiLstant. 

(e)  The  appearance  of  signs  of  compression  of  the 
lung  below  the  angle  of  the  left  scapula,  viz.,  dulness, 
impaired  air  entry,  bronchophony,  and  often  tubular 
breathing. 

This  area  of  compression  does  not  extend  far  forward 
into  the  axilla  and  is  important  evidence  of  pericarditis, 
since  it  does  not  appear  to  be  produced  by  pure  dilatation 
of  the  heart.  It  is,  however,  often  present  in  dry  peri- 
carditis, and  is  then  due  to  under  action  of  the  left  half  of 
the  diaphragm. 

ii— ^ 


260  MEDICAL   DIAGNOSIS 

{/)  Bulging  of  the  prsecordiiim  and  intercostal  spaces 
to  the  left  of  the  sternum.  This  is  only  likely  to  occur 
in  children,  and  may  also  be  caused  by  extreme  dila- 
tation. 

(g)  A  pulsus  paradoxus  may  be  present  (vide  p.  220). 
In  large  effusions  there  is  a  tendency  for  the  fluid  to 
collect  behind  and  below  the  heart.  If  the  urgency  of 
the  case  seems  to  warrant  exploration  either  from  a 
diagnostic  or  a  therapeutic  point  of  view,  we  liave  to 
decide  where  to  explore. 

The  site  usually  recommended  for  paracentesis  is  the 
fifth  left  interspace  three-quarters  of  an  inch  from  the 
sternum.  In  our  opinion  it  is  more  likel}^  that  a  dilated 
right  ventricle  will  be  tapped  in  this  situation,  and  we 
advise  that  exploration  should  be  carried  out  either  in 
the  sixth  left  space  at  the  junction  of  the  anterior  and 
middle  thirds  of  the  axiUa  or  else  in  the  sixth  right  space 
half  an  inch  from  the  sternum  in  the  cardio-hepatic  angle, 
or  perhaps  in  the  chondro-xiphoid  angle  on  the  left  side 
through  the  diaphragm  and  above  the  peritoneum. 

It  must  be  remembered  that  in  very  few  cases  of  sero- 
fibrinous effusion  is  exploration  justified. 
Pericardial  friction  must  be  distinguished  from  : — 

{a)  Pleura -pericardial  Friction.  This  is  produced  by 
inflammation  between  the  pleura  covering  the  lung 
fringes  and  the  pericardium  that  is  in  contact  with  them. 
There  is  a  double  rhythm  in  pleuro-pericardial  friction, 
partly  cardiac  and  partly  respiratory;  hence  it  is  modified, 
or  even  abolished,  if  the  patient  holds  his  breath.  It  is 
usually  heard  along  the  left-hand  border  of  the  super- 
ficial cardiac  dulness,  and  is  not  likely  to  be  audible  to 
the  right  of  the  middle  line  as  well  as  in  this  region. 
True  pericardial  friction  is  nearly  always  heard  to  the 
right  of  the  middle  line  at  the  base  of  the  heart. 

[b)  Aortic  Valve  Disease.  A  double  aortic  murmur  may 
sometimes  be  mistaken  for  pericardial  friction,  but  its 
definite  lines  of  conduction,  the  fact  that  it  is  not 
modified  by  pressure,  its  identity  with  the  heart's 
sounds,  and  its  greater  remoteness  should  prevent  this 
mistake. 


r^TSEASES  OF  THE  rAPvDTO-VASrTLAR  SYSTEM   26] 

The  diagnosis  of  tuberculous  from  rheumatic  pericarditis 
must  rest  upon  the  existence  of  tuberculosis  elsewhere, 
especially  in  the  left  apex,  and  the  lack  of  rheumatic  history 
or  valvular  disease.  In  tuberculous  pericarditis  the  effusion 
is  sometimes  blood-stained. 

(ii.)  Suppurative  Pericarditis.  This  condition  may  be  met 
with  in  pneumonia  (either  by  direct  extension  or  by 
metarstasis),  in  septicaemia,  pyaemia,  and  in  mediastinal 
suppuration. 

The  diagnosis  is  but  rarely  made,  since  the  effusion 
is  purulent  from  the  out-et,  and  consequently,  there  may  be 
no  fibrin  formation  and  so  no  rub. 

The  condition  may  be  suspected  in  a  case  of  pneumonia 
or  pyaemia  if  there  is  evidence  of  pericardial  effusion, 
such  as  abrupt  increase  in  cardiac  dulness  with  a  more 
or  less  triangular  outline  and  at  the  same  time  marked 
pulse  acceleration  and  dyspnoea.  , 

If  pyo -pericardium  is  suspected  the  best  way  to  clinch 
the  diagnosis  is  to  explore  through  an  incision  made  parallel 
to  and  just  below  the  costal  margin  on  the  left  side  about  one 
inch  from  the  base  of  the  xiphisternum.  The  pericardium 
can  be  approached  through  the  diaphragm,  and  if  pus 
is  present  efficient  drainage  can  be  assured.  An  alternative 
method  is  to  excise  a  portion  of  the  sixth  left  rib  close  to 
the  costo-chondral  junction. 

(iii.)  Adherent  Pericardium.  This  condition  falls  natu- 
rally into  two  groups  : — 

(a)  Where  the  visceral  and  parietal  layers  of  pericardium 
are  tightly  bound  together,  but  where  there  is  no  undue 
adhesion  between  the  outside  of  the  pericardium  and  the 
chest  wall  or  thoracic  viscera. 

(h)  Where  there  are  adhesions  between  the  pericardium 
and  the  chest  wall  and  the  thoracic  viscera.     This  con- 
dition is  practically  a  chronic;  adhesive  mediastinitis. 
In  the  first  group  the  significance  depends  largely  upon 
the  age  of  the  patient.     In  an  adult  whose  heart  has  done 
growing  there  may  be  no  signs  or  sym])t()ms  of  the  condition 
until  there  is  eventually  some  call  for  hypertrophy  which 
the   heart  is  unable   to  meet.     In  children,   however,   the 
development  of  the  heart  is  seriously  hampered  and  symp- 


262  MEDICAL   DIAGNOSIS 

toms  of  dilatation  and  impairment  of  function  are  likely 
to  be  produced  from  the  outset.  In  any  case  a  heart  so 
restricted  cannot  face  any  extra  call  so  readily  as  when  the 
pericardial  space  is  not  obliterated. 

In  the  second  group  the  condition  is  more  serious,  for 
the  ordinary  action  of  the  heart  is  interfered  with  to  a  greater 
or  less  extent.     Again,  it  is  children  who  suffer  most. 

Symptoms  of  Adherent  Pericardium.  The  symptoms  are 
those  of  cardiac  hypertrophy  and  dilatation,  with  eventually 
failure  of  the  right  ventricle.  In  any  case  where  evidence 
of  endocarditis,  past  or  present,  does  not  seem  to  be  sufficient 
to  account  for  the  severity  of  the  cardiac  symptoms  present, 
adherent  pericardium  should  be  thought  of  and  the  following 
physical  signs  carefully  looked  for. 

Physical  Signs  of  Adherent  Pericardium  : — 

(a)  An  increase  in  the  size  of  the  heart  (as  evidenced  by 
the  increase  in  cardiac  dulness)  greater  than  can  be 
explained  by  any  valvular  disease  that  may  be 
present. 

(6)  A  very  diffuse  wavy  impulse,  often  with  a  soft 
tickling  diastolic  thrill. 

(c)  Fixation  of  the  Apex  Beat.  This  is  tested  by  pal- 
pating the  apex  and  at  the  same  time  rolling  the  patient 
over  on  to  his  left  side.  In  normal  hearts  the  apex  will 
move  out  from  1  to  2  inches.  This  sign  is  of  restricted 
value  in  children,  since  there  is  less  room  in  their  chests 
for  the  heart  to  swing. 

{d)  Systolic  sucking  in  of  the  lower  sternum  and  left 
costal  cartilages. 

(e)  Systolic  recession  of  the  intercostal  spaces  in  the  lower 
chest  at  the  apex,  and  also  at  the  back  and  in  the  axilla. 
Of  these  the  most  conclusive  is  recession  below  the  angle 
of  the  scapula  in  the  tenth  and  eleventh  spaces. 

N.B.  Both  (d)  and  (e)  may  be  produced  by  very  large 
hearts  in  children  in  the  absence  of  an  adherent 
pericardium. 

(/)  A  diastolic  shock  may  be  felt  from  the  recoil  of  the 
chest  wall  after  the  systole  is  over. 

(g)  A  presystolic  or  diastolic  murmur,  not  accompanied 
by  other  evidence  of  valvular  disease. 


DISEASES  OF  THE  CARDIO- VASCULAR  SYSTEM   2G3 

(h)  If  the  right  auricle  is  obstructed  by  band  forma- 
tion, progressive  anasarca  may  be  an  early  feature. 
Despite  the  above  list  of  signs,  it  remains  to  say  that  a  posi- 
tive diagnosis  is  often  impossible,  since  many  of  the  above 
signs  may  be  absent  in  adherent  pericardium  or  present 
when  there  is  no  lesion  other  than  cardiac  hypertrophy 
and  dilatation. 


XV.  ARTERIO-SCLEROSIS  (ATHERO-SCLEROSIS;. 

The  pathology  of  this  condition  is  obscure,  but  it  would 
appear  possible  to  recognise  two  main  groups — the  Toxic 
and  Degenerative. 

The  Toxic  form  maj^  be  produced  either  by  the  direct 
actions  of  certain  toxins  on  the  arterial  wall,  acting  pre- 
sumably through  the  vasa  vasorum  ;  or  else  the  toxins  may 
act  indirectly  by  causing  spasm  in  the  muscle  coat  of  the 
arteries,  the  result  of  which  is  to  raise  the  blood  pressure. 

The  Degenerative  form  may  be  considered  as  more  or  less 
physiological,  since  it  has  been  suggested  by  Jores  that  the 
capacity  of  the  arteries  for  compensatory  hypertrophy  fails 
at  the  age  of  40  to  keep  pace  with  the  steadily  rising  blood 
pressure.  Hence  after  this  age  more  or  less  degeneration 
is  to  be  expected  at  the  points  of  maximum  pressure  (the 
ascending  aorta)  and  the  points  which  are  structurally 
weakest  (the  points  of  bifurcation). 

With  the  exception  of  the  obliterating  endarteritis  of 
syphilis  it  seems  probable  that  the  primary  change  is  in 
the  middle  coat  of  the  vessel  and  that  the  obvious  secondary 
changes  in  the  intima  are  due  to  necrosis  following  lack  of 
nutriment.  It  has  been  shown  that  the  arteries  are  not 
nourished  at  all  by  the  stream  of  blood  passing  through 
them. 

Clinically  arterio-sclerosis  may  be  recognised  by  a  high- 
tension  pnlso,  a  hyportrophied  heart,  and  a  persistently 
raised  blood  pressure.  At  the  same  time  the  arteries  may 
be  palpably  thickened,  hard,  or  tortuous. 

There  may  be  no  Symptrms  for  years,  but  when  there  are 
symptoms  they  fall  into  three  groups — Cardiac,  Cerebral, 
and  Renal. 


2r,4  MEDICAL  DIAGNOSIS 

The  cardiac  manifestations  are  breathlessness  on  exertion, 
coldness  of  the  extremities,  fainting  attacks,  and  anginoid 
pains. 

The  cerebral  manifestations  are  vertigo,  headaches,  epi- 
leptiform  seizures,  transient  paralysis,  noises  in  the  head, 
and  insomnia. 

The  renal  manifestations  are  those  of  interstitial  nephritis 
(vide  p.  446). 

XVI.  AORTIC  ANEURYSM. 

It  is  customary  to  describe  aneurysms  as  being  either 
fusiform,  saccular,  or  dissecting.  In  the  great  majority  of 
cases  when  aneurysm  is  discussed  "  saccular  "  aneurysm  is 
meant.  The  fusiform  variety  is  rare,  since  a  fusiforni 
dilatation  of  the  ascending  aorta  is  very  seldom  worthy 
of  being  considered  an  aneurysm  either  clinically  or  patho- 
logically. Dissecting  aneurysm  is  also  rare  ;  it  is  caused 
by  a  rent  in  the  intima  followed  by  an  inrush  of  blood  into 
the  media,  which  splits  the  wall  of  the  aorta  longitudinally 
for  a  varying  distance.  Under  these  circumstances  hfe  is 
rarely  prolonged  for  more  than  a  few  hours,  death  being 
preceded  by  rupture  of  the  external  coats  either  into  the 
pericardium  or  elsewhere.  The  only  symptom  is  agonising 
precordial  pain,  which  maybe  felt  to  spread  along  the  course 
of  the  aorta. 

The  following  remarks  apply  principally  to  saccular 
aneurysms  of  the  aorta  : — 

The  signs  and  symptoms  of  aortic  aneurysm  differ  very 
greatly  according  to  what  part  of  the  aorta  is  affected.  It 
is  best  therefore  to  consider  the  general  symptomatology  of 
aneurysm  and  then  to  discuss  shortly  the  individual  aneu- 
rysms of  the  different  parts  of  the  aorta. 

(i.)  General  Symptomatology.  The  symptoms  produced 
are  due  to  the  pressure  of  the  aneurysm  on  various  adjacent 
structures  and  it  is  impossible  to  dissociate  completely 
symptoms  from  signs. 

Pain  may  be  dull  and  aching  from  pressure  on  the 

chest  waU,  it  may  be  neuralgic  from  pressure  on   the 

nerve  trunks,  or  it  may  be  lancinating  and  paroxysmal 


DISEASES  OF  THE  CARDTO-VASCULAR  SYSTEM    265 

from   erosion   of   the   vertebrae   and   implication   of   the 
posterior  nerve  roots. 

Anginoid  pain  {vide  p.  257)  may  be  caused  by  aneurysm 
of  the  intra-pericardial  portion  of  the  aorta. 

Pressure  of  the  sac  upon  the  trachea  may  produce  cough, 
as  well  as  dyspnoea,  stridor,  bronchitis,  bronchorrhoea.  and 
haemoptysis. 

Pressure  on  the  root  of  the  lung  may  produce  cough  and 
])ulmonary  collapse. 

Pressure  on  the  left  recurrent  laryngeal  nerve  may 
produce  a  brassy  cough,  hoarseness,  or  loss  of  voice  from 
abductor  paralysis  of  the  left  vocal  cord  ;  or  irritation  of 
the  same  nerve  may  produce  severe  paroxysmal  dyspnoea. 

Pressure  on  the  vagus  nerve  may  produce  dyspnoea, 
vomiting,  or  hiccough. 

Pressure  on  the  left  phrenic  nerve  may  paralyse  the 
left  half  of  the  diaphragm. 

Pressure  on  the  superior  vena  cava  or  left  innominate 
vein  may  produce  venous  engorgement  without  pul- 
sation or  respiratory  modification.  This  phenomenon 
is  unilateral  when  the  left  innominate  vein  is  concerned. 

Pressure  on  the  sympathetic  nerve  fibres  may  produce 
unequal  pupils  (dilated  from  irritation  and  contracted 
from  paralysis),  and  also  unilateral  flushing,  sweating  and 
bristling  of  the  hair  on  the  face. 

Pressure  on  the  oesophagus  may  produce  dysphagia. 
A  consideration  of  the  anatomy  of  the  aorta  makes  it 
obvious  that  the  majority  of  these  pressure  effects  can  only 
be  produced  by  an  aneurv'sm  of  the  transverse  part  of  the 
arch  or  one  at  the  top  of  the  descending  atora.  These  parts 
of  the  aorta  are,  however,  deeply  situated,  and  aneurysms 
of  them  are  not  so  likely  to  give  rise  to  physical  signs  as  arc 
aneurysms  of  the  ascending  aorta  which  is  more  superficial 
and  also  has  more  room  for  expansion. 

(ii.)  The  Physical  Signs  of  Aortic  Aneurysm  may  be  : — 

(a)  Visihle  or  Palpable  Pulsation. — This  is  evident 
above  the  base  of  the  heart,  more  often  to  the  right  of 
the  sternum  than  to  the  left  ;  it  should  be  ex])ansil(\ 
and  may  only  be  apparent  on  careful  examination  made 
tangentially  and  in  a  good  fight.     On  the  other  hand, 


266  MEDICAL   DIAGNOSIS 

there   may  be    an   obvious   pulsatile    tumour  projecting 
through  the  chest  wall. 

(b)  An  Increased  Area  of  Dulness,  especially  to  the  right 
of  the  sternum  in  the  first,  second,  and  third  spaces. 

(c)  A  Thrill,  systolic  in  time,  over  the  upper  part  of  the 
sternum. 

{d)  A  Low-pitched,  Ringing  Second  Sound  over  the  aortic 
area.  This  is  one  of  the  most  important  signs  of  aneurysm. 
It  is  produced  in  the  same  manner  as  is  the  next  sign. 

{e)  A  Diastolic  Shock,  due  to  the  recoil  of  the  distended 
sac. 

(/)  A  Systolic  Murmur.  The  chief  importance  of  the 
systolic  murmur  is  that  it  should  be  heard  over  the 
aorta  rather  than  at  the  aortic  valve  area. 

(gr)  A  Tracheal  Tug.  To  elicit  this  the  patient  should 
sit  in  a  chair  with  his  neck  extended,  and  the  observer 
should  stand  behind  the  chair  and  place  his  thumbs, 
one  from  each  side,  under  the  patient's  cricoid  cartilage 
which  should  be  firmly  but  gently  pressed  upwards. 
The  tug  will  be  felt  as  a  definite  systolic  pull.  The  cardiac 
pulsation  may  sometimes  be  felt  in  this  manner  when 
there  is  no  aneurysm,  and  many  aneurysms  of  the  trans- 
verse arch  fail  to  give  the  sign. 

Qi)  Inequality  of  the  Pulses.  The  left  radial  pulse 
may  be  retarded  and  of  smaller  amplitude  than  the 
right  where  there  is  an  aneurysm  distal  to  the  innominate 
artery  but  proximal  to  or  involving  the  left  subclavian. 
This  phenomenon  should  be  checked  by  observation 
of  the  brachial  and  carotid  pulses,  in  order  to  exclude 
an  aberrant  radial  artery. 

ii)  Signs  of  Collapse  in  some  part  of  the  left  lung  from 
obstruction  to  the  left  bronchus  (the  right  lung  is  more 
rarely  affected). 

(j)  Unless  there  is  aortic  valve  disease,  the  heart  is 
not  enlarged  to  percussion  and  the  position  of  the  impulse 
is  unaltered. 

In  reviewing  the  signs  and  symptoms  detailed  above 
it  is  evident  that,  with  the  exception  of  an  expansile  tumour 
and  possibly  the  altered  second  sound  and  the  diastolic 
shock,  there  are  none  that  are  pathognomonic  of  aneurysm. 


DISEASES  OF  THE  CARDIO-VASCrLAR  SYSTEM   267 

When,  in  addition,  we  remember  that  in  many  cases  of 
aneurysm  there  are  neither  signs  nor  symptoms  to  guide  us 
it  is  plain  that  the  diagnosis  of  this  condition  may  be  of  the 
utmost  difficulty. 

(iii.)  Aneurysm  of  the  Intrapericardial  Portion  of  the 
Aorta.  There  ma}-  be  no  symptoms  or  signs.  Death  often 
occurs  at  an  early  stage  from  rupture  into  the  pericardium. 
Occasionally  the  aneurysm  ulcerates  into  the  superior 
vena  cava  or  into  the  pulmonary  artery.  In  the  former 
case  there  is  sudden  extreme  congestion  of  the  veins  in 
the  head  and  neck,  with  severe  throbbing  headache,  oedema, 
and  dyspnoea  :    a  continuous  buzzing  murmur,  sometimes 


I'ui.  .">(>. — Pulse  tracings  from  thi>  right  and  l(ft  Radial  Arteries  of  a  man 
sufftring  from  Aneurysm  of  the  transversi-  aortic  arch.  The  upper 
tracing  is  from  the  right  wrist.  Note  the  inequality  of  the  tracings  and 
that  the  left  i^ulse  is  nearly  obliterated. 

acconi])anied  by  a  thrill,  may  be  apparent  in  the  aortic 
area.  In  the  latter  case  there  is  sudden  precordial  pain  with 
urgent  dyspnoea  ;  at  the  same  time  a  continuous  nuirmur 
like  tiiat  described  as  occurring  with  patent  ductus  arteriosus 
is  audible. 

The  most  likely  manifestations  of  aneurysm  in  this 
situation  are — angina  pectoris,  evidence  of  aortic  valve 
disease,  especially  aortic  reflux,  an  increased  area  of  dulness 
in  the  second  left  space,  and  pressure  on  the  superior  vena 
cava. 

(iv.)  Aneurysm  of  the  Ascending  Aorta  between  the  Peri- 
cardium and  the  Innominate  Artery.     This  is  (he  aneurysm 


268  MEDICAL   DIAGNOSIS 

of  physical  signs,  such  as  increased  duhiess  to  the  right  of 
the  sternum  in  the  second  and  third  spaces,  a  pulsating 
expansile  tumour  in  the  second  right  space,  a  low-pitched 
ringing  aortic  second  sound,  and  a  diastolic  shock.  A 
systolic  murmur  is  often  present,  but  by  itself  it  is  of  no 
diagnostic  value.  Possible  pressure  effects  are  pain  from 
pressure  on  the  chest  wall,  venous  congestion  from  pressure 
on  the  superior  vena  cava,  and  occasionally  collapse  of 
lung  as  shown  by  loss  of  breath  sounds,  with  at  first  unaltered 
percussion  note  from  pressure  on  the  root  of  the  right  lung. 

(v.)  Aneurysm  of  the  Transverse  Aortic  Arch.  This  is 
the  aneurysm  of  symptoms,  due  to  pressure  effects  on  the 
trachea,  left  bronchus,  oesophagus,  left  recurrent  laryngeal 
nerve,  sympathetic  nerves,  or  even  the  left  innominate  vein. 
If  the  aneurysm  grows  to  a  large  size,  there  may  be  a 
hePcving  pulsation  at  or  above  the  manubrium  sterni,  with  a 
considerable  increase  of  dulness  to  percussion  in  the  second 
spaces.  A  systolic  murmur  audible  about  the  episternal 
notch  and  not  heard  at  the  aortic  area  is  suggestive,  as  is  a 
diastolic  shock.  Unequal  pulses  and  a  tracheal  tug  are 
important  diagnostic  points  of  aneurysm  in  this  position. 

(vi.)  Aneurysm  of  the  Descending  Aortic  Arch.  Here 
there  are  often  neither  signs  nor  symptoms  for  a  long  time. 
This  aneurysm  may  give  a  tracheal  tug,  signs  of  pressure 
on  the  left  bronchus,  left  recurrent  lar5mgeal  nerve  or 
oesophagus,  and,  most  important  of  all,  severe  root 
pains,  indicative  of  erosion  of  the  fourth  and  fifth  dorsal 
vertebrse. 

(vii.)  Aneurysm  of  the  Descending  Thoracic  Aorta  gives 
the  same  signs  as  the  above,  except  that  tracheal  tug  and 
pressure  on  the  left  bronchus  or  recurrent  laryngeal  nerve 
are  not  met  with,  and  the  root  pains  will  indicate  involve- 
ment of  lower  vertebrae.  In  very  rare  cases  a  pulsating 
tumour  has  appeared  in  the  back. 

(viii.)  Aneurysm  of  the  Abdominal  Aorta.  This  is  usually 
situated  opposite  the  second  lumbar  vertebra  where  the 
coelic  axis  is  given  off. 

A  definite  pulsating  tumour  may  be  formed  if  the  bulge 
is  forwards.  It  is  important  not  to  mistake  transmitted 
pulsation  from  an  excitable  aorta  ;    the  test  is  to  ascertain 


DISEASES  OF  THE  CARDIO-VASCULAR  SYSTEM   269 

whether  the  pulsation  is  expansile.  Not  infrequently  the 
aneurysm  grows  from  the  back  of  the  aorta  and  erodes  the 
vertebral  column,  when  root  pains  are  the  first  evidence 
of  illness. 

Differential  Diagnosis.  In  considering  the  differential 
diagnosis  of  aneurysm  it  is  important  to  remember  the  factor 
played  by  syphilis  in  its  production  and  the  rarity  with  which 
women  are  affected.  Over  90  per  cent,  of  aortic  aneurysms 
occur  in  syphilitic  patients,  so  that  a  negative  Wassermann 
reaction  is  very  much  against  the  diagnosis  of  aneurj'^sm. 
The  most  important  method  of  diagnosis  at  our  disposal  is 
undoubtedly  the  fluoroscope.  By  means  of  the  X-ray 
screen  it  is  possible  to  detect  a  pulsating  tumour  in  the 
course  of  the  aorta  in  nearly  every  case  of  aneurysm. 

Thoracic  aneurysm  may  be  indistinguishable  clinically 
from  mediastinal  new  growth.  The  X-rays  may  settle  the 
question  at  once,  but  if  they  do  not  do  so  it  is  possible  to 
estimate?  to  some  extent  the  probabihties  of  the  case  by  the 
consideration  of  the  following  points  : — 

(a)  A  low-pitched  ringing  aortic  second  sound  and  a 

diastolic  shock  are  both  very  much  in  favour  of  aneurysm. 
(6)  Relief  of  symptoms,  such  as  pain  and  dyspnoea,  by 

rest   in  bed,   and   especially   the   re-aeration  of  hitherto 

collapsed  lung,  is  in  favour  of  aneurysm. 

(c)  The  relief  of  pain  by  potassium  iodide  is  only 
slightly  in  favour  of  aneurysm,  since  many  inflammatory 
processes  are  temporarily  benefited  by  this  drug. 

(d)  Abductor  paralysis  of  the  left  vocal  cord  is  slightly 
in  favour  of  aneurysm. 

(e)  Retardation  and  diminution  of  the  left  radial  pulse, 
in  the  absence  of  enlarged  axillary  glands,  is  in  favour  of 
aneurysm. 

(/)  A  definite  tracheal  tug  is  greatly  in  favour  of 
aneurysm. 

(g)  Enlarged  supra-clavicular  or  axillary  glands  or  the 
evidence  of  prinuiry  malignant  disease  anywhere  is  in 
favour  of  new  growth. 

{h)  Enlarged  superficial  thoracic  veins,  with  the  blood- 
stream running  from  above  downwards,  is  slightly  in 
favour  of  new  growth. 


270  MEDICAL   DIAGNOSIS 

(^)  Displacement   of    the    heart   is    in   favour    of   new 

growth. 

(j)  Pleurisy  is  in  favour  of  new  growth. 

{k)  Persistent  pain  in  the  chest,  not  lancinating  root 

pain^  is  slightly  in  favour  of  new  growth. 

(l)  A    negative    Wassermann   reaction    is    very    much 

against  aneurysm. 

(w)  The  age  of  the  patient,  the  evidence  of  arterial 

degeneration,  and  the  length  of  history,  may  afford  con- 
siderable help  in  excluding  new  growth. 

Aortic  Regurgitation  with  marked  pulsation  of  the  aorta 
may  sometimes  be  mistaken  for  aneurysm.  The  X-ray 
screen  will  show  whether  there  is  dilatation  of  the  ascending 
aorta  or  whether  true  aneurysm  is  present.  It  should  be 
remembered  that  per  se  aneurysm  does  not  cause  cardiac 
hypertrophy,  so  that  marked  enlargement  of  the  left  ventricle 
would  favour  primary  aortic  reflux. 

It  should  be  remembered  that  an  aneurysm  of  the  first 
part  of  the  aorta  may  affect  the  aortic  valves  and  so  give 
rise  to  reflux. 

Gastric  Crises  and  Girdle  Pains  may  suggest  the  possibility 
of  abdominal  aneurysm.  The  other  signs  of  tabes  dorsalis 
should,  however,  prevent  error.  The  fluoroscope  should 
prevent  root  pains  due  to  primary  vertebral  or  meningeal 
causes  being  attributed  to  aneurysm. 


CHAPTER   II 

DISEASES  OF   THE    RESPIRATORY  TRACT  AND   PLEURA 

I.  ANATOMY. 

The  trachea  is  4|  inches  long  ;  it  commences  at  the 
cricoid  cartilage,  which  is  at  the  level  of  the  sixth  cer- 
vical vertebra,  and  terminates  opposite  the  fourth  dorsal 
vertebra  by  dividing  into  the  right  and  left  bronchi. 
Its  course  is  downwards  and  distinctly  backwards,  a  fact 
which  is  emphasised  in  babies  and  is  of  importance  in 
tracheotomy.  The  arch  of  the  aorta  crosses  in  front  of  the 
lower  part  of  the  trachea  and  turns  downwards  above  and 
behind  the  left  bronchus.  The  left  pulmonary  arter;^  forms 
at  first  a  superior  and  then  an  anterior  relation  of  the  left 
bronchus.  The  left  recurrent  laryngeal  nerve,  as  it  winds 
round  the  arch  of  the  aorta  from  before  backwards,  forms 
a  superior  relation  of  the  left  bronchus.  The  apices  of  the 
lungs  reach  for  about  1|  inches  above  the  clavicles  ;  the 
bases  are  somewhat  hollowed  out  by  the  domes  of  the 
diaphragm.  The  anterior  borders  of  the  lungs  run  from  the 
apex — that  is  to  say,  a  point  towards  the  posterior  border  of 
the  sterno -mastoid  muscle  1^  inches  above  the  clavicle — 
down  through  the  sterno-clavicular  articulations  to  reach 
the  mid-point  of  the  sternum  at  the  level  of  the  second 
cartilages.  From  this  point  the  lines  run  side  by  side  till 
the  level  of  the  fourth  costal  cartilages  is  reached,  where 
they  diverge.  The  right-hand  line  is  continued  down  the 
middle  of  the  sternum  to  the  level  of  the  fifth  cartilage, 
when  it  curves  rather  abruptly  outwards  to  the  sixth  right 
chondro-sternal  articulation.  The  left-hand  line  curves,  with 
its  convexity  forwards,  out  to  the  fourth  left  chondro-sternal 
junction,  and  thence,  following  the  edge  of  the  superficial 
cardiac  dulnoss,  proceeds  in  another  curve  to  the  sixth  left 
costo-chondral  junction  {vide  Fig.  40). 

The  lower  borders  of  the  lungs  are  represented  by  slightly 


272  MEDICAL   DIAGNOSIS 

convex  lines  running  from  the  sixth  right  chondro-sternal 
junction  and  the  sixth  left  costo-chondral  junction  respec- 
tively to  the  sjiinous  process  of  the  tenth  dorsal  vertebra. 
The  lower  borders  of  the  lungs  will  be  at  the  seventh  rib 
in  the  anterior  axillarj^  line,  at  the  eighth  rib  in  the  posterior 
axillary  line,  and  at  the  tenth  rib  in  the  line  of  the 
scapular  angle. 

The  line  dividing  the  upper  from  the  lower  lobe  is 
obtained  by  joining  the  spine  of  the  second  dorsal  vertebra 
with  the  sixth  rib  in  the  nipple  line.  The  upper  border 
of  the  middle  lobe  on  the  right  side  is  indicated  by 
a  line  joining  the  mid-point  of  the  interlobar  hne 
above  mentioned  and  the  fourth  right  chondro-sternal 
junction. 

The  pleura  extends  for  at  least  one  inch  below  the  level 
of  the  lung  all  round. 

II.    EXAMINATION    OF    THE     CHEST    IN 
HEALTH    AND    DISEASE. 

(a)  Inspection.  The  spherical  chest  of  infancy  develops 
into  an  ellipse  with  its  long  axis  transverse  by  the  third 
year.  Both  halves  of  the  chest  should  be  symmetrical  one 
with  the  other,  though  the  circumference  of  the  right  side 
may  be  a  quarter  of  an  inch  more  than  the  left. 

Asymmetry  of  the  chest  can  be  demonstrated  by  the 
cyrtometer,  which  is  composed  of  two  lengths  of  malleable 
lead  tubing  hinged  together.  The  hinge  is  applied  to  a 
spinous  process  and  the  lead  is  accurately  moulded  to  the 
chest.  The  instrument  can  be  removed  and  the  outline 
traced  on  paper  for  permanent  record. 

The  chest  may  be  symmetrical  and  yet  show  the  following 
deviations  from  the  normal  : — 

The  Flat  Chest  shows  a  diminution  in  the  antero -posterior 
diameter  ;  the  costal  cartilages  are  unusually  straight,  and 
sometimes  the  sternum  is  more  or  less  depressed.  The  con- 
dition is  congenital  and  appears  to  predispose  to  pulmonary 
tuberculosis. 

The  Winged  Chest  is  small  in  all  dimensions,  but  especially 
antero-posteriorly  ;    the  ribs  and  shoulders  droj)  and  the 


Fii;.  .")!.     Diaj^rain  to  show  : 

(i.)  The  curve  assumed  Itythc  upper 
level  of  free  fluid  in  the  Pliura 
(Damoiseau  s  curve)  :  Dotted 
black  line. 
(ii.)  The  lines  dividint;  the  lobes  of 
the  ri<;ht  luuu  :  l)ott(d  red 
lines, 
(iii.)  The  lower    level    df    the    L\u\^: 

I'ppc  r  blue  line. 
(iv.)  'i'he   lower  level  if    the    IMeura; 
Lower  iiiue  line. 


DISEASES    OF   THE   RESPIRATORY   TRACT      273 

scapulae  are  thrown  outwards.  The  condition  is  con- 
genital, and  is  sometimes  associated  with  pulmonary 
tuberculosis. 

The  Pigeon  Chest  is  almost  triangular  in  transverse 
section  owing  to  undue  prominence  of  the  sternum  ;  it  is 
often  associated  with  Harrison^s  sulcus,  which  is  a  deep 
transverse  groove  at  the  level  of  the  fifth,  sixth,  and 
seventh  ribs.  Both  these  conditions  are  due  to  force:! 
inspiration  during  infancy  and  childhood  when  the  bony 
structures  are  still  soft.  Predisposing  causes  are  whooping- 
cough,  broncho-pneumonia,  and  rachitis. 

Rachitis  tends  to  produce  a  vertical  groove  at  the  costo- 
chondral  junctions  owing  to  the  pull  of  the  diaphragm 
on  the  softened  epiphyses  of  the  ribs  and  also  a  beading 
of  the  ribs  (rickety  rosary)  at  the  same  place. 

The  tendency  of  long-continued  forced  inspirations  is  to 
increase  the  capacity  of  the  chest  to  its  maximum.  /  This 
is  well  seen  in  emphysema,  where  the  chest  becomes  circular 
or  barrel  shaped  and  the  cervico-dorsal  region  of  the  spinal 
column  becomes  bowed  forwards. 

Unilateral  deformities  of  the  chest  may  be  produced  by 
spinal  curvatures,  by  chronic  pulmonary  disease,  or  by  over- 
action  of  one  lung  ;  localised  bulgings  by  aneurysm  or  new 
growth,  general  bulging  by  a  large  pleural  effusion,  especially 
if  purulent  or  by  pneumothorax. 

Shrinking  or  wasting  is  especially  noticeable  at  the  apices, 
and  is  significant  of  fibro-caseous  tuberculosis,  fibroid  lung, 
or  adherent  pleura.  Complete  collapse  of  one  lung,  as 
from  pressure  by  an  aneurysm  or  tumour,  may  produce 
a  distinct  falling  in  of  one  half  of  the  chest. 

Inspection  of  the  chest  also  shows  the  movements  and 
method  of  expansion.  The  ordinary  respiration  rate  is 
16  to  18  per  minute  for  men  and  20  to  22  for  women  :  in 
children  it  is  more  rapid  ;  in  infancy  it  is  30  to  35  per 
minute.  Men  breathe  largely  by  the  exercise  of  the 
diaphragm  (abdominal  type  of  respiration)  ;  young 
chiklren  use  this  method  almost  exclusively  ;  women,  on 
the  other  hand,  possibly  owing  to  the  use  of  corsets, 
breathe  noticeably  with  their  intercostal  nnisdes  (co.stal 
type).     Hence  bilateral  impairment   of    ex]iansion   at  the 


274  MEDICAL   DIAGNOSIS 

apices  is  more  significant  in  women  than  in  men.  The 
maximum  expansion  of  the  chest  should  be  at  least  one 
twelfth  of  its  mean  girth  greater  than  the  minimum 
expansion. 

Local  impairment  of  expansion  suggests  local  disease 
of  the  lung  or  pleura  ;  it  must  be  remembered,  however, 
that  in  old  or  debiUtated  people,  especially  those  who  are 
bed -ridden,  there  is  often  a  very  limited  apical  expansion 
from  prolonged  disuse. 

The  nerves  to  the  intercostal  muscles  may  be  paralysed 
from  spinal  lesions,  with  the  result  that  more  strain  is 
thrown  on  the  diaphragm,  and  conversely  the  action  of 
the  diaphragm  may  be  seriously  interfered  with  by  ascites, 
sub -phrenic  abscess,  abdominal  tumours,  etc.,  with  the 
result  that  the  accessory  muscles  of  respiration  are  caUed 
into  play. 

Dijsjmoea  signifies  difficulty  of  respiration  and  is  a  term 
that  is  used  rather  loosely  ;  thus  in  lobar  pneumonia, 
though  there  is  always  a  great  increase  in  the  number  of 
the  respirations  (tachypnoea),  there  is  very  often  no  diffi- 
culty in  drawing  the  breath.  In  cardiac  conditions  and 
renal  disease,  on  the  other  hand,  true  dyspnoea  is  extremely 
common. 

Dyspnoea  may  be  inspiratory  or  expiratory  ;  in  the  former 
case,  if  accompanied  by  stridor,  it  signifies  some  definite 
obstruction  to  air  entry.  Expiratory  dyspnoea  is  seen 
principally  in  emphysema  and  bronchial  asthma  and  broncho- 
pneumonia in  children.  Orthopnoea  is  an  advanced  stage 
of  dyspnoea  in  which  the  patient  cannot  breathe  unless  he 
is  sitting  up. 

Air-hunger  is  seen  in  certain  toxic  conditions,  such  as 
diabetic  coma  and  other  forms  of  acidosis,  and  is  charac- 
terised by  very  deep  and  prolonged  inspirations. 

In  adults  the  normal  respiratory  cycle  consists  of  inspira- 
tion, expiration,  and  then  a  pause.  In  infants  the  cycle 
is  expiration,  inspiration,  and  then  pause. 

This  infantile  type  of  respiration  persists  for  about  six 
months,  but  any  child  up  to  two  years  or  more  who  gets  an 
acute  pulmonary  lesion  often  reverts  to  the  infantile  type 
of  respiration  for  the  time  being. 


DISEASES   OF  THE    RESPIRATORY   TRACT      275 

Obstructive  stridor,  as  mentioned  above,  is  mainly 
inspiratory,  and  must  not  be  confounded  with  the  expiratory 
grunt,  which  is  so  characteristic  a  feature  of  bronclio- 
pneumonia  in  young  chikh"en. 

Cheyne- Stokes  respiration  consists  of  a  series  of  shallow 
respirations  which  graduall}'  become  more  and  more  frequent, 
deeper  and  noisier,  till  they  are  positively  distressing  ;  they 
then  subside  in  the  inverse  order  and  terminate  in  a  complete 
cessation  of  respiration  (apnoea)  which  may  last  for  twelve 
to  fourteen  seconds.  The  whole  cycle,  including  the  pause, 
usually  occupies  about  fifty  seconds.  The  phenomenon 
is  seen  in  ursemia,  coma,  cerebral  disease,  myocardial  disease, 
opium  poisoning,  sometimes  in  acute  infections,  and  occa- 
sionally in  healthy  children  who  are  asleep.  As  a  rule 
Cheyne-Stokes  respiration  is  an  indication  that  death 
is  at  hand. 

Slowing  of  the  respiration  rate  is  common  in  unconscious- 
ness and  collapse  ;  it  is  also  a  manifestation  of  digitalis 
and  other  drug  poisoning. 

Increased  frequency  of  respiration  is  usual  in  fevers  ; 
it  is  also  common  where  there  is  dyspnoea  that  is  not  ob- 
structive, in  pulmonary,  cardiac  and  renal  disease,  and  in 
many  neurotic  conditions. 

(b)  Palpation.  This  is  carried  out  with  the  flat  of  the  han  1: 
it  is  of  use  in  confirming  variations  in  degrees  of  mobility 
as  suspected  by  inspection,  and  also  for  testing  the  tactile 
vocal  fremitus.  Sometimes  friction  sounds  may  be  palpable 
(just  as  are  certain  cardiac  murmurs),  and  coarse  rhonchi 
can  often  be  felt. 

The  tactile  vocal  fremitus  represents  the  vibrations  of  the 
spoken  voice  conducted  from  the  larynx  througli  the  air  in 
the  bronchial  tubes  to  the  chest  wall  and  so  to  the  examining 
hand,  in  health  it  is  slightly  greater  over  the  right  lung 
than  over  the  left. 

In  women  and  children  it  may  be  very  sliglit.  For  eliciting 
it,  resonant  words  such  as  nine,  ninety-nine,  and  nine 
hundred  and  ninety-nine  are  the  best. 

Tactile  vocal  fremitus  is  increased  over  solid  lung  if  ti'e 
solid  tissues  are  homogeneous  ;  thus  it  is  loud  in  pneumonia, 
but  often  diminished  over  a  tumour ;  it  is,  of  course,  not  well 

18—2 


276  MEDICAL   DIAGNOSIS 

perceived  unless  the  bronchi  communicating  with  the 
particular  affected  area  are  patent.  It  may  be  increased 
over  a  cavity  which  is  near  the  surface  and  which  communi- 
cates with  a  bronchus. 

In  pleural  effusion,  emp3^ema,  pneumo -thorax  and  very 
thickened  pleura  it  may  be  absent. 

It  is  sometimes  more  convenient  to  use  the  ulnar  border 
rather  than  the  flat  of  the  hand  for  investigating  the  tactile 
vocal  fremitus. 

In  all  cases  bilateral  variations  from  the  normal  are  not 
nearly  so  important  as  unilateral,  and  it  must  be  borne  in 
mind  that  extreme  adiposity  may  completely  cut  off  the 
vibrations. 

(c)  Percussion.  The  middle  finger  of  the  left  hand 
(except  for  left-handed  individuals)  is  the  best  pleximeter 
and  the  middle  finger  of  the  right  hand  is  the  best 
plessor.  The  pleximeter  finger  must  be  firmly  applied 
to  the  chest  wall  and  must  be  struck  at  right  angles 
on  the  part  between  the  base  of  the  nail  and  the  ter- 
minal joint  by  the  pulp  of  the  plessor,  the  nail  of  which 
should  be  kept  very  short.  The  blow  should  be  short 
and  staccato,  delivered  with  a  free  wrist,  from  the  wrist 
only,  and  never  from  the  elbow  or  shoulder  ;  it  must  be 
fight  yet  firm. 

The  force  of  the  blow  must  vary  in  different  cases,  neces- 
sarily being  greater  in  fat  or  muscular  subjects,  but  as  a 
general  rule,  and  always  in  children,  light  percussion  affords 
more  information  than  heavy. 

In  outlining  an  organ  the  pleximeter  finger  must  be  kept 
parallel  to  the  assumed  edge  of  the  viscus.  The  object  of 
percussion  is  to  compare  the  note  obtained  (1)  with  the 
normal  note  for  that  position,  (2)  with  the  corresponding 
area  of  the  opposite  side,  but,  in  addition  to  this,  valuable 
information  is  gained  from  the  feeling  of  resistance  obtained 
by  the  act  of  percussion  in  different  conditions  of  health 
and  disease. 

Percussion  sounds  are  described  as  being  resonant,  hyper- 
resonant,  tympanitic,  dull  or  flat. 

A  resonant  note  is  obtained  over  healthy  lung  tissue  and 
is  heard  at  its  best  towards  the  apex  of  the  axilla. 


DISEASES   OF   THE    RESPIRATORY   TRACT      277 

A  hyper -resonant  note  is  characteristically  obtained  over 
emphysematous  lungs. 

A  tympanitic  note  differs  from  hyper -resonance  in  that 
the  air  producing  it  is  not  sub  -divided  into  numerous  small 
compartments  as  in  healthy  lungs  ;  this  imparts  a  drum-like 
character  to  the  percussion  note  which  is  best  appreciated 
in  pneumo-thorax,  or  over  a  cavity  which  is  near  the  surface 
and  which  communicates  with  a  patent  bronchus. 

Where  the  air  has  no  outlet,  as  in  closed  cavities  and  some 
cases  of  pneumo-thorax,  the  pitch  of  the  note  varies  directly 
with  the  tension  of  the  walls.  The  result  may  be  a  duU  note 
in  cases  where  the  tension  is  very  high. 

Skodaic  resonance  or  sub -tympany  is  a  peculiar  box^'  note, 
rather  like  that  normally  obtained  over  the  trachea  when 
the  mouth  is  open  ;  it  is  characteristically  present  over  the 
lung  above  a  good-sized  pleural  effusion  and  also  where  there 
is  a  central  consolidation  separated  from  the  chest  w^ll  by 
a  thinnish  layer  of  aerated  lung,  as  in  the  early  stages  of 
man}^  cases  of  pneumonia. 

A  completely  dull  note,  as  normally  heard  over  the  hver, 
depends  for  its  generation  entirely  on  the  impact  of  the 
percussion  blow  ;  there  is  no  vibration  imparted  to  the  air  as 
when  the  healthy  lungs  are  percussed.  In  addition  the 
resiliency  or  power  of  vibration  of  the  chest  wall  maj^  be 
completely  or  partially  destroyed,  and  it  is  this  latter  factor 
which  explains  the  difference  (even  more  of  feel  than  of 
sound)  which  obtains  when  percussion  is  made  over  solid 
lung  and  over  pleural  effusion.  Both  notes  may  be  abso- 
lutely dull,  but  the  sensation  where  there  is  fluid  is  that  of 
striking  a  very  thick  blanket,  antl  where  there  is  consolida- 
tion of  strildng  a  very  thick  board.  The  dead,  toneless 
sound  of  the  note  over  fluid  is  called  "  flat  '  and 
may  be  nearly  approximated  to  by  percussing  the  thigh 
muscles. 

The  bruit  de  pot  Jele  or  crack-pot  sound  is  a  metallic 
chinking  sometimes  heard  when  percussion  is  made  over  a 
cavity  which  communicates  with  a  bronchus  when  the 
patients  mouth  is  open.  It  is  also  to  be  heard  on  percussing 
the  chests  of  healthy  infants  who  are  crymg. 

In  percussing  a  chest  it  is  important  to  remember  that 


278  MEDICAL   DIAGNOSIS 

the  note  over  the  right  apex  is  normally  rather  higher  pitched 
(duller)  than  that  over  the  left,  and  that  the  liver  dulness 
is  perceived  at  the  sixth  rib  on  the  right  side  in  front,  at 
the  eighth  rib  in  the  mid-axillary  line,  and  at  the  ninth  rib 
in  the  line  of  the  scapular  angle. 

On  the  left  side  the  presence  of  the  heart  must  be  allowed 
for  {vide  p.  207),  and  possibly  also  the  spleen  {vide  p.  178), 
while  in  certain  cases  a  distended  stomach  may  produce 
a  tympanitic  note  extending  quite  high  up  into  the  left 
axilla. 

The  lower  border  of  lung  resonance  behind  reaches  to 
the  tenth  rib  in  expiration  and  to  the  eleventh  rib  in  forced 
inspiration  on  the  left  side  and  about  half  an  inch  higher  on 
the  right  side.  In  emphysema  these  limits  maybe  consider- 
ably exceeded. 

If  the  vertebrae  are  percussed  it  will  be  found  that  the 
upper  four  dorsal  vertebra?  are  dull,  while  the  lower  eight 
give  a  more  or  less  resonant  note  (osteal  resonance). 

(d)  Auscultation.     Three  classes  of  phenomena  should  be 
investigated  by  auscultation  : — 
(i.)  Breath  Sounds, 
(ii.)  Voice  Sounds, 
(iii.)  Adventitious  Sounds. 
It    does   not    matter   what    method   of    auscultation   is 
employed  ;    for  most  purposes   the  binaural  stethoscope, 
provided  that  the  ear-pieces  are  of  sufficient  size  and  the 
pressure  in  the  ears  enough  but  not  too  much,  is  the  best, 
it  is  well  to  remember  that  direct  auscultation  will  often 
reveal   as   much   as   a  stethoscope,   and   sometimes   more, 
especially  in  the  case  of  children. 

(i.)  Breath  Sounds.  The  vesicular  breath  sow?^fZ  as  heard 
over  healthy  lung  tissue  is  composed  partly  of  the  breath 
sounds  generated  at  the  glottis  and  modified  by  conduction 
through  the  spongy  lungs,  and  partly  of  the  murmur  manu- 
factured locally  in  the  terminal  bronchioles  and  puhnonary 
alveoli.  It  consists  of  a  soft,  rustling  inspiratory  sound 
t  s  long  as  the  act  of  inspiration,  followed  ivithout  any  pause 
by  a  still  softer  and  much  shorter  expiratory  sound  the 
length  of  which  is  not  more  than  one-third  that  of  the 
expiratory  act. 


DISEASES   or   THE    RESPIRATORY   TRACT      279 

Bronchial  breathing  is  heard  normally  over  the  trachea 
and  large  bronchi  and  pathologically  over  areas  of  consoli- 
dation or  cavities.  It  represents  the  muuodified  glottic 
breath  sounds  conducted  by  the  air  in  the  trachea  and  main 
bronctii.  It  consists  of  an  inspiratory  and  expiratory 
sound  of  equal  length,  of  higher  pitch  than  the  normal, 
and  separated  by  a  distinct  interval.  It  can  be  heard  in 
health}^  chests  over  the  bronchi  at  their  origin  from  the 
trachea. 

Tubular  breathing,  or  extreme  bronchial  breathing,  is 
heard  over  the  larynx  in  health  and  over  superficial  con- 
solidations and  cavities  or  collapsed  lung  to  which  a  patent 
bronchus  runs.  It  is  higher  pitched  than  true  broncliial 
breathing  and  has  a  characteristic  whiffing  sound.  The 
expiration  may  be  even  longer  than  the  inspiration,  and  is 
frequently  of  considerably  higher  pitch.  When  consolida- 
tion is  developing  a  "tubular  whiff  "  imparted  to  a  lenglfhened 
expiratory  sound  and  a  pause  between  inspiration  and 
expiration  are  often  the  first  detectable  signs. 

Prolongation  of  expiration  without  alteration  of  pitch 
and  without  a  pause  is  characteristic  of  emphysema. 

Diminution  or  absence  of  breath  sounds  may  occur  in  the 
very  fat  or  the  very  muscular,  but  if  it  stUl  persists  in  spite 
of  forced  respiration  it  is  likely  to  be  caused  by  thickened 
pleura,  pleural  effusion,  pneumo -thorax,  collapse  of  lung, 
new  growth,  or,  in  some  cases,  by  massive  consolidation 
where  the  main  bronchi  are  all  choked  up. 

Cavernous  breathing  is  bronchial  breathing  of  very  low 
pitch  and  hollow  quality.  It  indicates  an  empty  cavity  of 
a  size  at  least  that  of  a  walnut. 

Amphoric  breathing  resembles  cavernous  save  that  there 
is  a  resonant  quality  \vhich  can  be  simulated  by  blowing 
across  the  mouth  of  an  empty  bottle.  It  is  significant  of 
pneumo-thorax  or  a  large  superficial  cavity  communicating 
with  a  patent  bronchus.  It  may  be  accompanied  by  a 
definite  metalhc  tinkle,  which  is  accentuated  on  speaking  or 
coughing. 

Bronc/oo-vesicular  breathing,  as  its  name  impfies,  indicates 
a  mixture  of  bronchial  and  vesicular  breath  sounds.  It  can 
noiiually  be  iicard  in  the   second   interspace   close    to  the 


280  MEDICAL  DIAGNOSIS 

sternum  and  better  on  the  right  side  than  on  the  left. 
This  type  of  breathing  when  heard  elsewhere  is  often 
significant  of  early  tuberculous  change,  and  tubercu- 
losis is  often  diagnosed  in  healthy  people  because  the 
normal  occurrence  of  broncho-vesicular  breathing  in  the 
second  space  near  to  the  sternum  is  not  sufficiently  borne 
in  mind. 

Harsh  breathing  is  ordinarily  present  in  young  children, 
otherwise  it  may  be  one  of  the  earliest  signs  of  inflammatory 
change.  It  must  not  be  forgotten  that  the  breath  sounds 
at  the  right  apex  are  normally  rather  harsher  and  of  slightly 
higher  pitch  than  are  those  at  the  left. 

(ii.)  Voice  Sounds.  The  sound  of  the  spoken  voice  is 
generated  at  the  glottic  aperture  and,  as  heard  through  the 
stethoscope,  is  modified  very  much  by  the  conditions  of  the 
lung  or  pleura.  In  health,  though  loud  and  resonant,  it  is 
indistinct  and  remote.  The  voice  sounds  are  increased 
where  there  is  solid  lung  and  also  where  there  is  an  empty 
cavity  communicating  with  a  patent  bronchus.  They  are 
diminished  where  there  is  pleural  effusion,  pneumo-thoraXj 
pulmonary  oedema,  or  collapse  of  lung. 

Bronchophony,  or  abnormal  loudness  and  apparent  near- 
ness of  the  voice  sounds,  either  spoken  or  whispered,  is 
characteristic  of  an  inflammatory  consolidation  or  an  open 
cavity. 

Pectoriloquy  is  really  an  extreme  degree  of  bronchophony 
in  which  the  spoken  or  whispered  voice  in  addition  to  being 
loud  and  close  is  also  particularly  clear  and  distinct. 
It  is  defined  as  representing  the  clear  transmission  of 
articulate  sound.  It  is  most  likely  to  be  heard  over  an 
open  and  superficial  cavity  or  a  superficial  patch  of  con- 
solidation. 

A  metallic  tinJde  accompanying  the  spoken  voice  is  only 
heard  in  cases  of  pneumo-thorax  or  very  large  and  quite 
superficial  cavities. 

Mgojphony  is  a  nasal  twang  or  bleating  sound  imparted  to 
the  voice  about  the  upper  level  of  a  pleural  effusion  and  also 
sometimes  in  the  neighbourhood  of  the  advancing  edge  of  an 
inflammatory  process,  such  as  pneumonia. 

(iii.)  Adventitious  Sounds.    i?/io/ic/a  are  produced  during 


DISEASES   OF   THE   RESPIRATORY   TRACT      281 

the  respiratory  cycle  by  the  forcible  passage  of  air  past  some 
mucous  plug  which  is  obstructing  the  lumen  of  the  tube  and 
tempora.rily  converts  it  into  a  whistle.  The  result  is  a 
snoring  or  whistling  sound  devoid  of  all  character  of  moisture. 
Rhonchi  are  therefore  classified  into  sonorous  or  sibilant,  as 
the  case  may  be. 

Rales  are  produced  by  the  passage  of  air  through  moist 
secretion  ;  hence  they  are  essentially  wet,  bubbly  sounds  and 
may  be  coarse  or  fine,  according  to  the  cahbre  of  the  tubi^ 
concerned. 

Crepitations  are  produced  by  the  forcing  open  of  the  finest 
tubes  and  alveolar  spaces  the  walls  of  which  are  stuck  to- 
gether by  more  or  less  sticky  secretion. 

III.  COUGH  AND  SPUTUM. 

(a)  Cough.  The  ordinary  purpose  of  a  cough  is  to  I'emove 
from  the  upper  air  passages — that  is  to  say,  fauces,  larynx, 
trachea,  or  main  bronchi — -either  a  foreign  body  or  excess 
of  secretory  products.  The  desire  to  cough  is  also  induced 
by  irritation,  as  from  inflammation  or  pressure  by  new 
growth  in  these  situations,  before  there  is  any  material  to  be 
removed,  or  reflexly  by  irritation  in  regions  which  are  remote 
hon\  the  larynx,  trachea,  or  bronchi.  It  is  worthy  of  note 
that  morbid  processes  affecting  the  intrinsic  lung  tissue  do 
not  2>^>'  <5e  cause  cougli,  and  it  is  when,  as  the  result  of  such 
morbid  processes,  the  bronchi  become  involved  that  cough 
supervenes. 

In  distinct  contrast  to  the  above  is  the  cough  which  is  at 
once  induced  reflexly  by  any  lesion  of  the  pleura.  Other 
varieties  of  the  reflex  cough  may  be  instanced  : — The 
stomach  cough  of  chronic  gastritis,  which,  however,  is  not 
infrequently  due  to  associated  pharyngitis  ;  the  barking 
cough  of  puberty  ;  the  cough  sometimes  present  in  associa- 
tion with  lesions  of  the  external  auditory  meatus,  which  is 
due  to  irritation  of  the  auditory  branch  of  the  vagus  nerve  ; 
tlie  cough  not  iiifrecpiently  present  when  there  is  turbinal 
hypera^sthesia  ;  and,  lastly,  the  purely  hysterical  cough  of 
the  bashful. 

It  is  convenient  sometimes  to  classify  cough  into  two  main 


282  MEDICAL   DIAGNOSIS 

groups  : — (1)  The  cough  productive,  and  (2)  the  cough 
unproductive.  Both  varieties  may  be  seen  in  the  different 
stages  of  an  ordinary  lobar  pneumonia.  In  the  early 
stages  there  is  an  unproductive  cough  because  of  the 
existing  pleurisy  ;  in  the  later  stages  the  cough  is  pro- 
ductive and  is  one  of  the  methods  by  which  the  disin- 
tegrating products  are  got  rid  of  during  the  stages  of 
resolution.  In  general  it  may  be  stated  that  the  cause 
of  a  productive  cough  will  be  found  by  examination  of 
the  thorax,  such  conditions  as  bronchitis,  bronchiectasis, 
oedema,  and  tuberculosis  each  possessing  fairly  character- 
istic physical  signs. 

Those  coughs  which  are  produced  by  pressure,  as  from 
new  growth  or  aneurysm,  at  first  are  commonly  unproductive, 
but  later,  when  stenosis  has  occurred  and  permitted  more  or 
less  damming  up  of  secretion,  expectoration  may  be  profuse. 
Under  such  circumstances  the  physical  signs  may  be  localised 
to  one  lung  or  to  part  of  one  lung. 

In  conclusion,  certain  common  types  of  cough  may  be 
enumerated  : — The  paroxysmal  cough  of  pertussis,  which 
terminates  in  the  characteristic  whoop  ;  the  brassy  cough  of 
aneurysm  and  sometimes  of  mediastinal  tumour  ;  the 
hoarse  barking  cough  of  laryngitis  ;  and  the  hollow  racking 
cough  of  advanced  tuberculosis. 

(b)  Sputum.  For  diagnostic  purposes  examination  of  the 
sputum  must  be  considered  from  four  points  of  view  : — 
(i.)  Naked-eye  appearances  ;  (ii.)  amount  ;  (iii.)  odour  ; 
(iv.)  microscopical  characteristics. 

The  sputum  may  be  mucoid,  muco-purulent  or  purulent ; 
it  may  be  white,  yellow,  black,  or  mixed  in  varying  propor- 
tions with  blood  ;  it  may  be  frothy  or  entirely  free  from 
admixed  air.  If  placed  in  water  it  may  sink  to  the  bottom 
in  nummular  masses,  a  feature  which  is  commonly  observed  in 
tuberculosis  and  resolving  pneumonia.  In  chronic  bronchitis 
and  emphysema  the  sputum  is  muco-purulent  and  charac- 
teristically white  and  frothy.  In  bronchiectasis  and  advanced 
tuberculosis  it  is  profuse,  purulent,  and  usually  malodorous. 
In  oedema  of  the  lungs  the  sputum  is  profuse,  watery,  and 
stained  the  colour  of  prune  juice  ;  while  in  cases  of  advanced 
back  pressure  from  mitral  disability  cells  may  be  present 


DISEASES   OF   THE    RESPIRATORY   TRACT      283 

which  contain  numerous  granules  of  brown  pigment.  In 
gangrene  of  the  lung  the  sputum  is  profuse  and  has  so  charac- 
teristic an  odour  that  mistake  is  well-nigh  impossible. 
In  malignant  disease  of  the  lung  the  sputum  is  said  to 
resemble  red-currant  jeUy,  and  it  is  likened  to  anchovy 
sauce  in  those  cases  in  which  a  tropical  abscess  of  the  liver 
has  ulcerated  into  a  bronchus. 

The  expectoration  of  the  white  fibrinous  cast  of  a  bron- 
chial tree  is  only  met  with  in  fibrinous  bronchitis.  The 
sputum  of  those  who  live  in  towns  is  always  more  or  less 
blackened  by  carbonaceous  particles,  a  characteristic  which 
is  emphasised  in  miners,  coalheavers,  stokers,  etc. 

The  microscopical  appearance  of  sputum  may  be  of  the 
utmost  diagnostic  value  ;  by  this  means  the  causative 
organism — e.g.,  pneumococcus,  streptococcus,  or  micro- 
coccus catarrhahs — may  be  determined  after  suitable 
cultivation,  while  the  tubercle  bacillus  can  often  be  demon- 
strated in  film  preparations. 

In  addition  the  foUowing  features  may  be  noted. 
Curschmann's  spirals,  which  are  mucinous  casts  of  the  small 
bronchioles,  and  eosinophile  cells  are  commonly  present  in 
bronchial  asthma.  Dittrich's  plugs,  which  are  minute, 
yellowish,  malodorous  masses  of  fatty  acids  and  bacteria, 
are  characteristic  of  advanced  decomposition  either  in  lung 
tissue  or  in  old-standing  cavities.  Elastic  fibres,  which  may 
be  demonstrated  after  boihng  sputum  in  10  per  cent,  caustic 
potash,  are  pathognomonic  of  gangrene  or  tuberculosis. 
Calcareous  particles  may  be  expectorated  in  cases  of  healed 
tuberculosis. 

(c)  Haemoptysis.  In  considering  a  case  of  ha?moptysis  it  is 
necessary  lirst  to  establish  whether  the  blood  is  really 
derived  from  the  lungs  ;  for  this  purpose  a  careful  examina- 
tion of  the  mouth,  nose,  fauces,  and  naso-pharynx  is  neces- 
sary. In  this  manner  it  may  be  po.ssible  to  exchide  gum-suck- 
ing, a  common  trick  of  malingerers  ;  haemorrhages  from  a 
pharyngeal  vein  ;  new  growth  of  the  mouth,  fauces,  pharynx 
and  accessory  sinuses  ;  ulceration  about  the  posterior  nares  ; 
and  lastly  adenoid  vegetations,  which  are  a  common  cause 
of  blood-stained  sputum  and  •blood  on  tin-  jhHow  "  in  vouu" 
children. 


284  MEDICAL   DIAGNOSIS 

It  is  also  necessary  to  establish  that  the  condition  is 
not  ha^matemesis.  Careful  questioning  will  usually  suffice  ; 
but  it  is  important  to  remember  that  in  profuse  hsematemesis 
the  blood  is  often  bright  red  at  first,  and  also  that  in  true 
haemoptysis  much  blood  may  be  swallowed,  to  be  vomited 
subsequently  in  a  black  and  altered  condition.  As  a  general 
rule  the  blood  in  haemoptysis  is  bright  red,  frothy  from  ad- 
mixed air  and  more  or  less  mixed  with  sputum  ;  its  reaction 
to  litmus  paper  is  alkaline,  whereas  in  hsematemesis  it  is 
acid  from  admixed  gastric  secretions.  In  its  mildest  form 
there  will  only  be  an  occasional  bright-red  streak  on  various 
portions  of  phlegm.  In  more  severe  cases  the  patient  will 
usually  describe  the  first  symptom  as  a  tickhng  in  the  throat, 
which  is  followed  almost  immediately  by  a  gush  of  bright 
blood  from  the  mouth. 

The  blood  in  haemoptysis  is  not  always  bright  red  ;  a 
tuberculous  cavity  may  be  filled  with  blood-clot,  which  in 
time  becomes  altered  and  may  be  coughed  up  later  in  black 
jelly-like  masses  ;  and  the  same  effect  is  produced  in  the 
later  stages  of  extensive  pulmonary  infarction.  By  far 
the  most  common  cause  of  true  haemoptysis  is  pulmonary 
tuberculosis  ;  it  is,  however,  well  to  remember  some  other 
if  less  common  causes. 

Slight  haemoptysis  of  the  streaky  variety  is  by  no  means 
rare  in  bronchitis,  both  acute  and  chronic,  while  in  bronchiec- 
tasis there  may  be  quite  severe  haemorrhage.  The  rusty 
sputum  of  lobar  pneumonia  has  been  described  elsewhere. 
Ulceration  of  the  trachea  or  bronchi,  whether  simple, 
syphihtic,  or  malignant,  may  give  rise  to  haemoptysis. 

Thoracic  aneurysm  may  leak  into  the  trachea  producing 
haemorrhage,  which  though  usually  fatal  is  not  necessarily 
so  at  once  ;  while  haemoptysis  from  back  pressure  or  infarc- 
tion in  cases  of  mitral  disease  is  a  matter  of  every-day 
experience. 

IV.  DISEASES  OF  THE  LARYNX. 

(i.)  Simple  acute  laryngitis  is  associated  with  more  or  less 
severe  hoarseness,  sometimes  proceeding  to  entire  loss  of 
voice    and    unproductive    painful    cough.      The   disease  is 


DISEASES   OF   THE   RESPIRATORY   TRACT      285 

usually  of  fairly  rapid  onset,  and  the  laryngoscope  shows 
no  changes  other  than  a  varying  degree  of  congestion  of  the 
laryngeal  mucosa.  There  is  commonly  an  associated  catarrh 
of  the  naso-pharynx.  trachea,  and  bronchi. 

(ii.)  Simple  chronic  laryngitis  isusually  found  in  those  who 
habitually  overuse  their  voices,  and  especially  in  those  who 
have  no  knowledge  of  elocution.  Predisposing  factors 
undoubtedly  are  excess  of  alcohol  or  tobacco  and  chronic 
nasal  obstruction.  The  symptoms  are  a  chronic  hawking 
cough  and  a  more  or  less  permanent  huskiness  of  voice. 

Tuberculosis,    syphilis,    and    malignant     disease     of    the 
larynx   produce    a  chronic  laryngitis  and  have  been  con- ' 
sidered  on  p.  88. 

(iii.)  (Edema  of  the  larynx  is  a  secondary  infection  and 
is  most  commonly  met  with  in  cases  of  faucial  cellulitis ; 
it  may  also  occur  as  a  sequel  of  any  variety  of  ulcerative 
larj'ngitis,  the  ingestion  of  corrosive  substances,  the  inha- 
lation of  steam,  as  from  sucking  the  spout  of  a  kettle, 
the  sting  of  a  wasp  or  a  bee,  the  continued  administra- 
tion of  potassium  iodide,  in  angio -neurotic  oedema,  as  a 
complication  of  the  exanthems,  and  as  a  terminal  event  in 
nephritis. 

The  symptoms  are  those  of  laryngeal  obstruction — that 
is  to  say,  increasing  dyspnoea,  inspiratory  stridor,  inter- 
costal recession,  cyanosis,  and  a  rising  pulse  rate.  Inspection 
with  or  without  a  laryngoscope  will  show  a  red  oedematous 
epiglottis  and  swollen  aryteno-epiglottidean  folds. 

(iv.)  Spasmodic  laryngitis  {Laryngitis  stridulosa)  is  a  con- 
dition peculiar  to  infants  and  young  children.  The  glottis 
in  infancy  is  relatively  smaller  than  in  adult  life  ;  hence  a 
trivial  degree  of  inflammation  is  apt  to  produce  a  dispropor- 
tionate amount  of  distress  in  the  very  young,  and  when  there 
is  any  constitutional  disturbance  such  as  rickets  in  addition, 
and  sometimes  when  there  is  not,  a  recurrent  reflex  laryngeal 
spasm  is  apt  to  supervene.  The  clinical  picture  presented 
is  that  of  a  mild  laryngitis  with  a  hoarse  voice,  a  crowing 
inspiration,  and  attacks  of  spasmodic  coughing,  to  which 
may  be  added  transient  but  total  apnoea  from  laryngeal 
spasm.  The  spasmodic  attacks  tend  chiefly  to  occur  at 
night  and  may  persist  for  days  or  weeks. 


2Rr>  MEDICAL   DTA0N0ST8 

This  condition  should  not  be  confused  with  laryngismus 
stridulus. 

(v.)  Laryngismus  stridulus,  or  child  crowing,  is  simply 
an  expression  of  the  tendency  to  reflex  spasm  so  commonl}' 
present  in  infancy  when  the  nervous  mechanism  is  upset  by 
rickets,  indigestion,  teething,  or  worms.  In  mild  cases  there 
may  be  merely  a  periodical  bout  of  crowing  inspirations,  but 
in  more  severe  cases  suffocation  seems  imminent  owing  to 
sudden  and  violent  adductor  spasm  of  the  laryngeal  muscles 
and  not  infrequently  of  the  other  respiratory  muscles  also. 
Practically  always  the  spasms  will  terminate  spontaneously, 
and  the  air  then  rushes  into  the  lungs  with  a  characteristic 
crowing  sound.  There  is  no  associated  laryngitis,  and  the 
condition  must  be  regarded  as  purely  functional, 

V.  BRONCHITIS. 

(i.)  Acute  Bronchitis.  This,  as  the  name  implies,  is  an 
inflammatory  process  affecting  the  mucous  membrane  of  the 
bronchial  tubes.  The  inflammation  is  caused  by  one  or 
more  of  such  micro-organisms  as  micrococcus  catarrhalis, 
streptococcus,  staphylococcus,  the  pneumococcus,  the 
pneumo -bacillus,  or  the  influenza  bacillus,  except  in  those 
cases  where  the  inhalation  of  some  irritating  vapour  may 
have  caused  an  oedematous  condition  of  the  lining  membrane 
of  the  bronchial  tubes.  In  these  latter  cases  it  is  probable 
that  secondary  infection  with  micro-organisms  is  not  long 
delayed.  One  attack  of  bronchitis  disposes  to  another,  and 
the  disease  is  particularly  likely  to  occur  in  alcoholics  and 
those  who  suffer  from  renal  disease,  mitral  disease,  or  pul- 
monary tuberculosis.  It  is  an  invariable  accompaniment  of 
bronchial  asthma. 

The  prognosis  in  acute  bronchitis  may  be  said  to  vary 
directly  with  the  size  of  the  bronchial  tubes  affected  ;  the 
smaller  the  tube  the  more  serious  the  outlook.  When  the 
capillary  bronchioles  are  involved  the  condition  practically 
amounts  to  one  of  lobular  or  broncho-pneumonia,  under 
which  heading  it  M'ill  be  considered.  In  the  present  section 
acute  bronchitis  is  taken  to  mean  only  those  cases  in  which 
the  large  and  medium  bronchi  are  affected. 


DISEASES   OF   THE   RESPIRATORY   TRACT      287 

Course.  The  onset  is  usually  gradual,  and  it  is  often  possible 
to  trace  the  spread  of  the  infection  down  from  the  nose  or  the 
larynx  through  the  trachea  until  the  bronchi  themselves  are 
involved.  Commonly  there  is  a  tight  or  raw  feeling  across 
the  chest  with  general  malaise,  a  slight  rise  of  temperature — 
which  usually  does  not  amount  to  more  than  101°  in  adults, 
though  in  children  this  level  may  be  greatly  exceeded — and 
a  dry,  painful,  unproductive  cough.  In  two  or  three  days 
a  scanty,  viscid  secretion  becomes  sufficient  to  be  expecto- 
rated in  glairy  pellets.  At  this  stage  an  occasional  faint 
streak  of  blood  need  cause  no  alarm,  though  it  is  the  excep- 
tion rather  than  the  rule.  Gradually  the  cough  becomes 
looser,  the  expectoration  more  abundant  and  muco-purulent 
instead  of  viscid,  and  in  a  week  or  so  the  attack  may  be 
over. 

Signs  and  Symptoms.  At  the  outset  there  will  be  no 
physical  signs  except  a  few  scattered  rhonchi,  either  s>bilant 
or  sonorous,  probably  to  be  heard  best  at  the  base  of  the  lungs 
behind.  Occasionally  these  rhonchi  are  so  creaky  in  character 
and  so  localised  that  they  may  be  confused  with  a  pleuritic 
rub.  As  the  disease  progresses  the  rhonchi  will  be  accom- 
panied or  replaced  by  r^es  of  various  sizes  ;  these  may  be 
audible  over  the  entire  thorax,  but  are  usually  most  numerous 
in  the  lower  lobes. 

In  a  severe  attack  there  may  be  a  certain  amount  of 
cyanosis  and  dyspnoea.  These  symptoms  are  important  and 
may  mean  one  of  two  things  : — First,  that  the  right  lioart 
is  not  responding  well  to  the  additional  strain  :  this  is  likely 
to  be  the  case  in  a  person  who  suffers  from  chronic  bronchitis 
with  acute  exaceibations.  In  such  a  case  there  will  probably 
be  evidence  of  co -existing  emphysema  and  also  of  riglit- 
sided  cardiac  hj'pertrophy  ;  possibly  also  there  may  be 
clubbing  of  the  fingers.  Secondly,  they  may  mean  an 
involvement  of  tubes  so  fine  that  there  is  mechanical 
difficulty  in  the  passage  of  air  into  the  alveoli,  and  con- 
sequently imperfect  aeration  of  the  blood.  In  these  latter 
cases  the  rale.-  will  be  of  a  fine  character,  and  (•re))itations 
will  be  audible. 

The  diagnosis  of  acute  bronchitis  is  not  (lithciilt  ;  it 
should  not,  however,  be  mistaken  for  a'dema  of  the  lungs, 


288  MEDICAL   DIAGNOSIS 

in  which  there  are  symmetrical  areas  of  impaired  reso- 
nance in  the  most  dependent  portions  of  the  lungs  ; 
numerous  fine  crepitations,  both  inspiratory  and  expi- 
ratory, over  the  dull  areas  ;  profuse  watery  expectoration  ; 
and.  lastly,  some  evident  cause  for  the  oedema,  such  as 
a  failing  heart,  enforced  recumbency  in  aged  people,  and 
the  like. 

Unilateral  bronchitis  and  bronchitis  limited  to  the  upper 
lobes  should  at  once  excite  a  suspicion  of  possible  tubercu- 
losis, and  steps  should  be  taken  to  exclude  the  latter  disease. 
At  the  same  time  it  must  be  borne  in  mind  that  streptococcal 
and  influenzal  infections  are  often  strictly  localised  and 
extremely  resistant  to  treatment.  In  such  cases  careful 
bacteriological  examination  of  the  sputum  is  of  the  utmost 
value. 

(ii.)  Chronic  Bronchitis.  This  is  more  particularly  a 
disease  of  advanced  life,  but  it  is  by  no  means  infrequent 
in  childhood.  It  may  result  from  repeated  attacks  of  acute 
bronchitis  and  in  children  may  often  be  traced  to  an  attack 
of  whooping-cough  or  measles. 

The  continued  inhalation  of  irritating  material,  cardiac 
and  renal  disease,  and  any  chronic  pulmonary  lesion  are 
predisposing  factors.  It  is  nearly  always  at  its  worst 
in  the  winter,  and  may  indeed  disappear  temporarily  each 
summer. 

The  diagnosis  of  chronic  bronchitis  depends  on  the  history 
of  constant  or  periodic  cough,  which  in  the  great  majority 
of  instances  is  accompanied  by  the  fairly  free  expectoration 
of  muco-purulent  secretion.  The  sputum  is  often  described 
as  white  and  frothy.  This  character  depends  on  admixed 
air  and  is  the  result  of  the  emphysema,  which  is  a  constant 
accompaniment  of  chronic  bronchitis. 

Rdles  and  rhonchi  can  be  heard  in  the  chest,  especially  at 
the  bases  of  the  lungs,  while  the  special  physical  signs  of 
emphysema  {vide  p.  290)  are  usually  present.  As  a  rule 
there  is  singularly  little  constitutional  disturbance,  and  what 
there  is  can  usually  be  attributed  to  the  emphysema  rather 
than  the  bronchitis,  or  to  the  underlying  factor,  such  as 
cardiac  or  renal  disease,  which  is  the  cause  of  the  bronchitis. 
It  is  of  the  greatest  importance  not  to  overlook  cases  of 


DISEASES  OF  THE   RESPIRATORY   TRACT      289 

pulmonary  tuberculosis  when  the  predominant  features  are 
those  of  chronic  bronchitis.  To  exclude  the  former  repeated 
examinations  of  the  sputum  ma}^  be  necessary. 

The  prognosis  in  the  case  of  chronic  bronchitis  depends 
almost  entirely  on  the  iniderlying  cause  or.  if  no  underlying 
cause  can  be  established,  on  the  condition  of  the  right 
ventricle  at  the  time  of  examination. 

Fetid  Bronchitis  is  a  name  somewhat  arbitrarily  given  to 
cases  in  which  the  sputum  is  unusually  offensive.  The 
majority  of  such  cases  will  eventually  prove  to  have  some 
super-added  factor,  such  as  abscess  of  the  lung,  pulmonary 
gangrene,  or  bronchiectasis. 

(iii.)  FiBRixotrs  Bronchitis.  This  is  a  rare  condition, 
more  common  in  men  than  women,  and  is  characterised  by 
the  expectoration  of  a  firm  white  fibrinous  cast  of  the  whole 
or  part  of  one  of  the  bronchial  trees.  The  condition  has 
occasionally  been  noticed  in  connection  with  one  of^  the 
infectious  fevers  ;  more  commonly  it  is  of  a  chronic  type, 
the  paroxysms  occurring  at  regular  intervals,  often  through- 
out many  years.  Each  paroxysm  starts  rather  like  an 
attack  of  acute  bronchitis,  only  there  is  more  dyspnoea 
and  general  distress  ;  the  symptoms  increase  in  severity 
for  a  varying  number  of  hours  until  eventually  a  cast  is 
expelled  with  an  unusually  severe  attack  of  coughing. 

There  is  some  danger  of  suffocation  during  the  more 
severe  paroxysms.  The  condition  is  never  diagnosed  until 
a  cast  has  been  brought  up,  but  Avhen  once  this  has  occurred 
mistake  is  impossible. 

VI.  EMPHYSEMA. 

Emphysema  is  produced  as  the  result  of  violent  ex- 
])iratory  efforts  with  a  closed  glottis  or  when  there  is  some 
])ermanent  obstruction  to  free  ex])iration.  Long-contiiuied 
cough  is  by  far  the  most  common  cause.  The  strain  of 
oft-repeated  coughing  is  most  felt  by  the  weakest  parts 
of  the  hiiig — namely,  the  alveoli.  The  greatest  effect 
is  produced  in  those  regions  in  which  the  thoracic  parictes 
offer  the  least  support  to  the  lungs — that  is  to  say,  at  the 

M.D.  19 


290  MEDICAL  DIAGNOSIS 

apices,  along  the  anterior  borders,  and  where  the  lungs  thin 
out  between  the  diaphragm  and  the  ribs. 

For  clinical  purposes  emphysema  may  be  divided  into 
four  classes  : — Large-lungecl  or  hypertrophic  emphysema, 
small-lunged  or  atrophic  emphysema,  compensatory 
emphysema,  and  interstitial  or  surgical  emphysema. 

When  the  term  "  emphysema  "  is  used  clinically  it  is  the 
first  group  that  is  usually  meant. 

The  diagnosis  of  liypertropliic  emphysema,  when  advanced, 
does  not  permit  of  mistake.     The  patient  is  usually  more  or 
less  cyanosed  and  the  accessory  muscles  of  respiration  are 
freely  used.     The  chest  is  barrel-shaped  with  a  considerable 
increase  in  its  antero-posterior  diameter,  and  there  is  usually 
a  slight  kyphosis  of  the  upper  dorsal  vertebrae.     Clubbing 
of  the  terminal  phalanges  may  often  be  observed.      The 
whole  chest  is  hyper -resonant  to  percussion,  the  superficial 
cardiac  dulness  may  be  diminislied  or  obliterated,  and  lung 
resonance  may  be  obtained  as  low  as  the  eleventh  intercostal 
spaces.     On  auscultation  there  is  a  characteristic  harshening 
and  prolongation  of  expiration,  while  associated  bronchitis 
is  a  constant  feature.     The  long-drawn  expiration  will  be 
best  detected  at  the  apices  and  along  the  anterior  borders 
of  the  lungs  ;    indeed,  in  mild  cases  it  may  be  localised  to 
these  situations.     Owing  to  the  rupture  from  their  points 
of  attachment  of  the  inter -alveolar  walls  with  splaying  out 
of    the    infundibular    terminations    and    the    consequent 
obhteration  of  many  of  the  terminal  pulmonary  arterioles, 
there  is  very  great  obstruction  to  the  pulmonary  circulation. 
The  result  of  this  is  to  throw  an  increased  strain  on  the  right 
ventricle,  and  it  is  failure  of  the  right  heart  to  meet  this 
increased  demand  that  is  the  chief  complication  of  emphy- 
sema.   This  danger  of  right-heart  failure  is  greatly  enhanced 
by  the  liability  of  these  patients  to  recurrent  attacks  of 
acute  bronchitis. 

Small-lunged  or  atrophic  emphysema  is  of  pathological 
rather  than  clinical  interest.  It  results  from  atrophy  of 
the  alveolar  walls,  occurs  only  in  the  aged,  and  is  simply  a 
local  expression  of  the  diffuse  tissue  atrophy  which  occurs  in 
those  of  advanced  age. 

Compensatory  emphysema  is   produced  in  the  neighbour- 


DISEASES   OF  THE   RESPIRATORY  TRACT      291 

hood  of  chronic  puhnonary  lesions,  and  is  possibly  the  result 
of  a  local  attempt  of  the  healthy  lung  tissue  to  compensate 
for  the  impaired  activity  in  the  neighbourhood. 

Interstitial  emphysema  is  a  surgical  affection  whereby 
air  is  forced  into  the  mediastinal  tissues.  It  is  usually 
produced  by  trauma,  such  as  fractured  rib,  tracheotomy^ 
etc.,  but  has  been  described  in  cases  of  whooping-cough. 

VII.  BRONCHIECTASIS. 

The  same  factors  which  predispose  to  the  development 
of  emphysema  wiU  produce  bronchiectasis  instead,  pro- 
vided that,  as  the  result  of  previous  inflammation,  the 
bronchial  walls  have  become  so  softened  in  certain  places 
as  to  render  the.se  spots  the  weakest  portions  of  the  pul- 
monary system,  for  it  is  always  the  weakest  place  which 
yields  to  prolonged  strain.  The  old  idea  that  bronchi - 
ectatic  cavities  were  produced  directly  by  the  pull  of  con- 
tracting bands  of  fibrous  tis.sue  is  almost  certainly  fallacious, 
and  here,  just  as  in  emphysema,  the  essential  cause  is  a 
series  of  violent  expiratory  efforts  with  a  clo.sed  glottis. 

In  order  to  produce  the  requisite  areas  of  local  bronchial 
softening  more  or  less  damming  up  of  infected  secretion 
is  necessary,  and  this  will  necessarily  be  effected  by 
anything  which  produces  a  partial  occlusion  of  a  bronchus 
or  bronchiole  ;  again,  diseases,  such  as  tuberculosis  and 
pneumonokoniosis,  which  permit  of  extensive  fibrous  tissue 
formation  in  a  given  area  of  lung  tissue  are  likely  to  produce 
pouching  or  pocketing,  whereby  infected  secretion  may  lie 
stagnant  for  a  considerable  period  even  though  there  is  no 
obstruction  to  the  outflow,  with  the  result  that  bronchi- 
ectasis eventually  supervenes. 

Partial  occlusion  of  a  bronchus  may  be  produced  from 
within  by  the  inhalation  of  a  foreign  body,  by  ulceration 
(simple,  tuberculous  or  syphilitic)  or  by  new  growth  ;  or 
from  without  by  the  pressure  of  a  mediastinal  tumour  or 
aneurysm. 

Clinically  bronchiectasis  may  be  divided  into  acute  and 
chronic. 
Acute  Bronchiectasis  is  relatively  rare  and  might  perhaps 

19—2 


292  MEDICAL   DIAGNOSIS 

more  correctly  be  called  bronchiolectasis.  Its  incidence  is 
practically  confined  to  young  children,  and  it  is  seen  as  a 
complication  (frequently  fatal)  of  whooping-cough,  measles, 
or  capillary  bronchitis.  In  these  cases  there  is  a  diffuse 
softening  of  the  bronchiolar  walls  throughout  both  lungs  ; 
the  strain  of  the  severe  coughing  causes  widespread  dilata- 
tion of  these  softened  areas  and  an  appearance  not  unlike 
that  of  a  honeycomb  results.  The  condition  is  not  likely 
to  be  diagnosed  apart  from  co-existing  capillary  bronchitis, 
but  it  may  possibly  be  suspected  from  the  unusually  profuse 
and  offensive  expectoration  and  the  prevalence  of  large 
moist  rales. 

Chronic  Bronchiectasis  v/ili  often  depend  for  diagnosis 
rather  upon  the  history  of  the  case  and  character  of  the 
expectoration  than  on  any  very  definite  physical  signs. 
There  will  usually  be  a  history  of  chronic  bronchitis  for  a 
varying  number  of  years  ;  this  may  have  developed  insidi- 
ously, but  not  infrequently  it  may  be  traced  to  whooping- 
cough  or  measles  in  childhood  or  to  pulmonary  tubercu- 
losis, broncho-pneiimonia,  unresolved  lobar -pneumonia,  or 
empyema.  Gradually  the  patient  will  notice  a  progressive 
loss  of  strength  and  weight,  a  general  feeling  of  malaise 
with  tendency  to  perspirations,  a  notable  increase  in  the 
amount  of  sputum,  especially  on  waking  in  the  morning 
or  on  change  of  posture,  and  the  fact  that  the  sputum 
has  become  extremely  malodorous.  There  may  or  may 
not  be  clubbing  of  the  fingers  (pulmonary  osteoarthro- 
pathy). 

If  the  sputum  is  collected  and  allowed  to  stand  in  a  tall 
glass  jar  it  will  be  found  to  settle  in  three  layers  :  the  upper 
one  frothy,  the  second  clear,  and  the  lowest  one  purulent. 
Dittrich's  plugs  can  often  be  identified,  and  bacteriological 
examination  will  demonstrate  an  extreme  multiplicity  of 
organisms,  including  pneumococci,  streptococci,  staphy- 
lococci, micrococcus  catarrhalis,  B.  proteus,  B.  coh,  etc. 

The  odour  of  the  sputum  and  of  the  patient's  breath, 
though  not  so  appalling  as  in  cases  of  pulmonary  gangrene, 
is  nevertheless  sufficiently  characteristic  to  be  remembered 
when  once  it  has  been  experienced. 

The  physical  signs  are  very  variable  ;    there  will  always 


DISEASES   OF  THE   RESPIRATORY   TRACT      203 

be  evidence  of  chronic  bronchitis,  and  this  may  be  definitely 
more  severe  in  one  spot,  usually  towards  the  base  of  one 
lung.  Here  there  may  be  local  dulness,  possibly  with 
signs  of  cavitation  or  consolidation,  and  in  very  inarked 
cases  loud,  slushy  gurgles  may  be  audible.  If  one  lung 
only  is  affected,  that  side  of  the  chest  will  be  flattened  and 
shrunk,  with  poorer  expansion,  and  of  less  measurement 
than  the  other,  and  the  heart  may  be  pulled  over  to  the 
affected  area. 

The  differential  diagnosis  of  bronchiectasis  presents 
some  interesting  features.  It  must  be  remembered  that 
tuberculosis  is  the  most  common  cause  of  fibroid  lung, 
and  that  fibroid  lung  is  nearly  always  accompanied  by  more 
or  less  bronchiectasis.  At  the  same  time  extensive  fibrosis 
is  the  method  by  which  tuberculosis  becomes  healed  ;  hence 
it  is  quite  possible  to  have  bronchiectasis  which  was  primarily 
produced  by  a  tuberculous  process  but  in  which  all  -active 
tuberculosis  has  ceased.  Conversely,  tuberculosis  is  often 
grafted  secondarily  on  to  a  bronchiectatic  lung  which  has 
originated  from  some  other  cause. 

Repeated  examinations  for  tubercle  bacilli  should  be  made 
in  all  cases. 

From  a  purely  clinical  point  of  view  it  may  be  said 
that  the  restriction  of  the  signs  to  the  ba.ses  of  the  lungs 
is  against  tuberculosis,  but,  since  there  is  often  widespread 
bronchitis  at  the  same  time,  it  may  be  impossible  to  say 
whether  the  apices  are  free  or  not  On  the  other  hand 
apical  bronchiectasis  is  almost  certainly  tuberculous.  An 
empyema  that  has  ruptured  into  the  lung  may  easily  be 
(nistaken  for  bronchiectasis,  but  the  history  is  likeb/  to 
!)('  much  shorter,  and  as  a  rule  it  is  possible  to  get  evidence 
of  the  illness  from  which  the  empyema  dated. 

Unresolved  or  resolving  pneumonia  may  closely  simulate 
bronchiectasis  at  times,  more  especially  in  children  who  may 
have  lobar  pneumonia  without  the  obvious  symptoms 
which  occur  in  adidts.  The  course  of  the  case  will  prevent 
mistake  for  more  than  a  few  days. 


294  MEDICAL  DIAGNOSIS 

VIII.  FIBROSIS  OF  THE  LUNGS. 

A  fibrous  replacement  of  more  or  less  of  the  lung  tissues 
may  occur  in  a  variety  of  conditions  as  follows  : — 
(i.)  In  pulmonary  tuberculosis  {vide  p.  97). 
(ii.)  In  bronchiectasis  {vide  p.  291). 
(iii.)  As  a  sequel  to  unresolved  lobar  pneumonia  {vide 
p.  48). 

(iv.)  As  a  sequel  to  broncho-pneumonia, 
(v.)  As  a  sequel  to  chronic  dry  pleurisy, 
(vi.)  As  a  sequel  to  unrelieved  partial  collapse  of  the 
lung  from  any  cause. 

(vii.)  In  syphilis,  either  as  a  sequel  to  the  white  pneu- 
monia of  congenital  syphilis  or  as  the  result  of  gummatous 
deposits  in  acquired  syphilis.  It  should  be  noted  that 
syphilis  of  the  lung  is  extraordinarily  rare. 

(viii.)  In  the  form  of  pneumonokoniosis  which  develops 
as  a  sequel  to  the  constant  inhalation  of  irritant  particles 
in  the  course  of  certain  occupations,  for  example  : — 
(a)  Anthracosis,  in  coal  miners. 
(6)  Silicosis,  in  stonemasons  and  gold    miners  on  the 

South  African  reefs, 
(c)  Siderosis,  in  those  who  work  in  iron. 
The  most  common  cause  of  fibrosis  of  the  lungs  is 
tuberculosis,  though  the  incidence  of  pneumonokoniosis  is 
extremely  high  in  certain  occupations  ;  thus  80  per  cent, 
of  the  miners  engaged  in  blasting  operations  on  the  South 
African  gold  reefs  acquire  "  miner's  phthisis  "  within  three 
or  four  years,  though  probably  not  more  than  10  per  cent, 
of  these  are  infected  with  the  tubercle  bacillus.  At  the 
same  time  any  form  of  pulmonary  fibrosis  favours  the 
development  of  tuberculosis. 

Symptoms.  The  symptoms  attributable  to  fibrosis  of 
the  lungs,  from  whatever  cause,  are  cough  and  dyspnoea, 
especially  dyspnoea  on  exertion.  The  expectoration  may 
be  foul  if  there  is  any  bronchiectasis,  haemoptysis  is  not 
uncommon,  and  in  cases  of  anthracosis  the  sputum  is  often 
quite  black,  while  in  silicosis  bright  particles  of  silica  may 
be  detected  with  the  microscope. 

Physical  Signs.     The  affected  part  of  the  chest  is  retracted 


DISEASES   OF  THE   HESPlRATORY   TRACT      295 

and  moves  badly  or  not  at  all,  the  heart  is  pulled  over  towards 
the  fibroid  area  and  there  is  dulness  on  percussion.  Vocal 
fremitus  and  resonance  are  increased  locally  and  bronchial 
l)reathing  is  generally  heard.  Clubbing  of  the  fingers  may 
develop  in  old-standing  cases. 

There  are  nearly  always  more  or  less  diffuse  bronchitis 
and  compensatory  emphysema  in  the  healthy  parts  of  the 
lungs.  Where  the  fibrosis  is  of  sUght  extent  and  widely 
diffused  throughout  both  lungs,  as  may  happen  in  the 
earlier  stages  of  pneumonokoniosis,  the  physical  signs  are 
merely  those  of  chronic  bronchitis  and  emphysema. 

Diagnosis.  The  diagnosis  depends  on  the  history  and  the 
pliysical  signs  :  it  may  be  impossible  to  exclude  fibroid 
phthisis  except  by  the  repeated  absence  of  tubercle  bacilli 
from  the  sputum,  though,  on  the  whole,  it  may  be  said  that 
signs  restricted  to  the  base  of  a  lung  are  in  favour  of  fibrosis 
from  some  cause  other  than  tuberculosis.  / 


IX.  MEDIASTINAL  TUMOUR,   INCLUDING    NEW 
GROWTH  OF  LUNG. 

The  symptoms  of  this  condition  will  depend  almost 
entirely  on  pressure  exerted  on  surrounding  structures  and 
will  therefore  vary  with  the  precise  situation  of  the  tumour. 
The  earliest  thing  to  attract  attention  is  usually  cough  and 
dyspnoea  together  with  a  sense  of  oppression  in  the  chest. 

The  cough  may  be  produced  by  obstruction  or  ulcera- 
tion of  a  bronchus,  or  it  may  be  the  reflex  cough  of  pleuritic 
irritation  ;  if  the  recurrent  laryngeal  nerve  becomes  involved 
a  brassy  cough  like  that  of  aneurysm  will  result,  and  laryn- 
geal inspection  will  show  an  abductor  palsy  of  the  affected 
vocal  cord  (usually  the  left). 

Pain  may  be  an  early  symptom,  or  it  may  be  absent 
till  the  later  stages  ;  when  present  it  may  be  a  neuralgic 
])ain  from  irritation  of  nerve  teiminals,  a  stabbing  pain  from 
])leiu'isy,  or  the  agonising  pain  which  follows  erosion  of 
the  spinal  vertebra)  and  affection  of  the  posterior  nerve 
roots. 

The  tumour  may  come  to  the  surface  and  be  recognised 


296  MEDICAL  DIAGNOSIS 

as  a  round  or  irregular  swelling  which  does  not  possess  an 
expansile  pulsation,  though  pulsation  of  a  sort  maj^  be 
present  in  certain  very  vascular  sarcomata,  or  may  be  trans- 
mitted from  the  heart  should  this  organ  be  near  by. 

Pressure  on  the  great  veins  may  cause  great  congestion 
of  one  or  both  sides  of  the  head  and  neck,  while  dilated 
and  tortuous  veins  on  the  surface  of  the  chest  are  frequently 
developed  in  order  to  establish  collateral  circulation  through 
the  inferior  vena  cava  when  the  superior  vena  cava  has 
become  completely  or  partially  obliterated. 

Irritation  of,  or  extension  of  the  growth  to,  the  pleura  is 
likely  to  cause  effusion,  and  this  may  well  be  blood-stained, 
while  microscopical  examination  of  the  aspirated  fluid  may 
show  groups  of  cells  which  have  the  characteristic  features 
of  the  new  growth.  If  the  growth  has  originated  in  or 
extensiyely  involved  the  lung,  communication  between 
a  bronchus  and  the  pleura  may  be  estabhshed  and  empyema 
or  pyo-pneumo-thorax  will  follow.  Involvement  of  the  lung 
or  bronchi  will  also  produce  bronchitis  and  bronchiectasis 
with  profuse  expectoration,  sometimes  likened  to  red- 
currant  jelly  from  intimate  admixture  with  blood.  Severe 
haemoptysis  is  not  unknown. 

The  first  sign  of  mediastinal  new  growth  may  be  pro- 
gressive collapse  of  the  whole  or  part  of  one  lung,  as  shown 
by  increasing  diminution  of  air  entry,  followed  by  increas- 
ing clulness  and  tubular  breathing,  bronchophony,  and  the 
classical  signs  of  consolidation. 

The  heart  may  be  pushed  over  to  a  surprising  extent, 
and  the  aorta  or,  more  commonly,  one  of  the  pulmonary 
arteries  may  be  compressed  until  the  characteristic  murmurs 
of  obstruction  are  produced. 

It  will  be  seen  from  the  foregoing  that  a  great  variety  of 
signs  may  present  themselves,  but  that  no  single  one  is 
conclusive  evidence  of  mediastinal  growth  ;  hence  the  signs 
must  be  reviewed  as  a  whole  and  considered  in  conjunction 
with  the  history  and  appearance  of  the  patient. 

Valuable  assistance  may  be  obtained  from  the  use 
of  X-rays.  The  possibility  of  gunnna  must  never  be 
forgotten,  and  in  all  cases  a  Wassermann  reaction  should  be 
performed. 


DISEASES   OF  THE    RESPIRATORY   TRACT      297 

The  differential  diagnosis  between  tumour  and  aneurysm 
has  been  discussed  on  p.  269. 

Mediastinal  Ly.aiphadenoma  will  be  recognised  by  the 
enlarged  glands  in  the  neck,  groins  or  axilhie.  and  by  the 
big  spleen  and  liver. 

In  conclusion  we  may  say  that  a  true  mediastinal  neo- 
plasm is  most  likely  to  be  lymphosarcoma  or  endothelioma. 
A  new  growth  of  the  lung  may  be  primary,  in  which  case 
carcinoma  is  far  more  common  than  sarcoma,  or  secondarj^ 
in  which,  case  sarcoma  is  probably  more  common  than 
carcinoma,  though  primary  carcinoma  of  the  mamma  is 
responsible  for  a  considerable  number  of  secondary  growths 
in  the  lungs. 

X.  BRONCHO-PNEUMONIA    AND    CAPILLARY 
BRONCHITIS. 

(For  "  Tuberculous  Broncho-pneumonia,''  vide  p.  90.) 

This  disease  is  most  frequent  at  the  extremities  of  life, 
affecting  principally  infants  and  young  children  or  else  old 
and  debilitated  persons. 

Broncho-pneumonia  is  the  innncdiate  cause  of  death 
in  many  cases  of  injury  or  disease  affecting  the  skull  or 
brain,  because  those  who  are  unconscious  are  peculiarly 
liable,  first  to  inhale  septic  particles  from  the  mouth  and 
fauces,  and  secondly  to  be  unable  to  remove  thoroughly, 
by  coughing,  material  which  has  been  so  inhaled. 

For  a  like  reason  those  who  suffer  from  disease  of  the 
])harynx,  larynx,  or  upper  air  passages  are  especially  liable 
to  contract  this  complaint. 

This  variety  of  broncho-pneumonia  is  called  septic  or 
aspiration  pneumonia,  but  it  is  important  to  remember  that 
]uactically  all  cases  of  broncho-pneumonia  are  produced  by 
aspiration,  and  that  it  is  not  a  haMuatogenous  infection, 
as  is  lobar  pneumonia.^ 

Since,  then,  broncho-pneumonia  is  produced  by  the  spread 

'  Tilt-  |)()ssil)ility  of  the  pmuinoeoi'Hi.s,  or  some  other  organism,  causing  a 
Joljular  instead  of  a  lobar  infection  via  the  l)loo(l-stream  must  l)o  admitted, 
but  in  our  o|iinion  such  eases  are  rare  and  when  the_\  occur  produce  a  condi- 
tion which  clinically  resembles  lobar  pneumonia  rather  than  broncho-pneu- 
monia. 


298 


MEDICAL  DIAGNOSIS 


of  infection  down  the  bronchi  into  the  bronchioles  and  ulti- 
mately into  the  alveoli,  it  would  be  natural  to  expect  a 
patchy  distribution  of  inflammatory  areas  throughout 
the  lungs  and  also  great  diversity  of  causative  organisms. 
Further,  in  a  strict  sense,  the  disease  will  always  be  secondary 
to  some  infection  higher  up  in  the  respiratory  tract. 


1!; 

M    e 

M    E 

M   E 

M   £ 

M   E 

M  E 

M  E 

M  E 

M   E 

M   E 

M  E 

M  E 

M  E 

ME 

los' 

lO-f' 
103° 
.102° 
101° 
100° 
99° 
98° 
97° 
96° 

/' 

A 

f — ■' 

^ 

V 

:/ 

V 

■\ 

^ 

/ 

\ 

.-^ 

■r^ 

./ 

/ 

\/ 

V 

:/ 

/ 

/: 

--- 

.-. 

... 

'f 

■-• 

■»- 

... 

._. 

... 

■  ■•■ 

•  -- 

•  m' 

... 

-^. 

: 

Q. 

l-rO 
130 
120 
110 
100 
90 
SO 
70 
60 

L^ 

~-^ 

-— ^ 

^^ 

~^ 

■""^ 

^^ 

"T"*" 

L^^ 

■ 

■^- 

■■■ 

"7 

^' 

? 

1  r 

-jr 

h^ 

"A 

,   A 

... 

"7 

•  •• 

/ 

\J 

/ 

V 

V 

"    ' 

,/ 

1 

1 

55 
45 
33 
25 
1— /.« 

/ 

\ 

/: 

V 

:  / 

J 

v 

^ 

■ 

^^ 

_ 

^^M 

^^ 

^^^ 

,^^^ 

^^ 

^^ 

Fig.  52. — Chart  from  a  fatal  case  of  Broncho-Pneumonia 
in  a  child  of  two  years.  Note  the  extreme  rapidity 
of  both  pulse  and  respirations. 

These  conclusions  are  justified  by  post-mortem  and 
bacteriological  findings,  as  well  as  by  clinical  observation. 
The  organisms  of  broncho-pneumonia  include  staphylo-  and 
strepto-  cocci,  Friedlander's  bacillus,  the  bacillus  of  influenza, 
the  micrococcus  catarrhalis,  the  pneumococcus,  and  many 
others.  The  onset  is  usually  gradual  :  many  cases  follow 
measles  and  whooping-cough,  while  often  the  infection  can 
be  traced  to  an  ordinary  bronchitis  extending  to  the  smaller 


DISEASES   OF  THE   RESPIRATORY  TRACT      299 

tubes  until  the  capillary  bronchioles  are  affected  and 
broncho-pneumonia  results. 

The  clinical  picture  of  broncho-pneumonia  varies  greatly 
with  the  age  of  the  patient  ;  in  the  very  old  the  appearances 
are  often  masked  or  overshadowed  by  some  primary  disease 
and  the  pulmonary  condition  may  easily  be  overlooked. 
There  is,  however,  as  a  rule,  increasing  dyspnoea  and 
cyanosis,  a  rapid  pulse,  an  accelerated  respiration  rate,  and 
a  moderate  rise  in  temperature,  while  a  certain  amount  of 
cough  and  expectoration  is  inevitable. 

The  onset  in  infants  is  usually  gradual,  extending  over 
days  or  even  weeks  of  what  is  apparently  an  ordinary  but 
fairly  severe  bronchitis,  and  then  suddenly  the  child  becomes 
acutely  ill.  Less  commonly  there  maybe  obvious  broncho- 
pneumonia within  a  few  hours  of  the  first  symptom. 

The  physical  signs  may  only  be  those  of  fine  tube  basal 
bronchitis,  though  there  may  well  be  one  or  more  patches  of 
recognisable  consolidation.  Pulmonary  oedema  is  a  frequent 
accompaniment.  It  is,  however,  in  infants  and  young 
children  that  broncho-pneumonia  is  seen  in  its  most  charac- 
teristic form. 

The  expression  is  anxious,  the  face  livid  and  often 
cyanosed,  the  accessory  muscles  of  respiration  are  at  work, 
the  respirations  rapid  (60  to  80  per  minute)  and  often  of  the 
inverted  type  with  an  expiratory  grunt,  and  a  pause  at  the 
end  of  inspiration.  Vomiting  and  mild  convulsions  are 
common,  but  really  severe  fits  are  not  usual.  The  pulse  is 
rapid  (120  to  1 80  per  minute)  and  feeble,  and  the  temperature 
runs  a  markedly  irregular  course,  ranging  as  a  rule  between 
lOO''  and  103''  F.,  though  much  higher  readings  are  far  from 
uncommon. 

On  examining  the  chest  the  diaphragm  will  be  seen  to  be 
working  strongly  and  sucking  in  the  lower  ribs  with  each 
])reatli. 

Percussion  will  not  often  show  much  abnormality  ;  there 
may  be  relative  dulncss  at  one  or  both  bases  or  between  the 
scapulae,  but  more  often  there  are  areas  of  almost  hyper- 
resonance  from  local  emphysema.  In  well-marked  cases 
there  may  be  definite  areas  of  dulness  caused  by  fusion  of 
many   small   consolidated    areas.     Auscultation   will   show 


300  MEDICAL  DIAGNOSIS 

diffuse  rales  and  rhonchi,  with,  especially  at  the  bases  and  in 
the  interscapular  regions,  localised  patches  of  fine  crepita- 
tions ("  consonating  '"  rales),  and  possibly  here  and  there  an 
area  in  which  tubular  breathing  can  be  heard. 

Commonly  the  physical  signs  are  more  marked  in  one  lung 
than  tlie  other  ;  indeed,  one  lung  may  be  normal  throughout 
the  ilhiess  save  for  compensatory  over-action  and  emphysema. 
Occasionally  the  whole  of  one  lobe  may  become  solid  through 
fusion  of  many  patches  ;  more  often  signs  suggestive  of 
extensive  consolidation  are  due  to  collapse  of  the  lung. 

The  above  description  is  that  of  a  well-marked  case,  but 
the  diagnosis  of  broncho -pneumonia  is  warranted  whenever 
the  presence  of  very  fine  crepitations  in  the  lungs  is  combined 
with  cyanosis,  dyspnoea,  fever,  a  rapid  pulse,  very  rapid 
respirations,  and  an  expiratory  grunt.  The  ordinary 
duration  of  an  uncomplicated  case  is  from  two  to  six  weeks, 
the  temperature  eventually  falling  by  lysis.  As  a  general 
rule  the  more  abrupt  the  onset  the  shorter  will  the  ill- 
ness be. 

The  differential  diagnosis  does  not  present  any  difficulty 
as  a  rule. 

Acute  pericarditis  may  cause  a  similar  anxious  expression 
with  dyspnoea  and  cough,  but  there  will  be  no  evidence  of 
fine  tube  bronchitis,  and  the  characteristic  pericardial  fric- 
tion will  be  audible. 

Pleural  empyema  may  cause  some  doubt  because  it  may 
develop  in  the  course  of  broncho-pneumonia,  or  after  the 
acute  stage  of  broncho-pneumonia  is  over,  although  con- 
siderable bronchitis  may  still  be  present. 

The  absolute  dulness,  together  with  diminished  tactile  and 
vocal  fremitus,  the  presence  of  a?gophony,  and,  above  all, 
the  displacement  of  the  heart  will  usually  be  sufficiently 
suggestive  to  warrant  an  exploratory  puncture  with  a  needle. 
Further,  in  empyema  the  condition  is  not  so  acute  ;  the 
dyspnoea  is  not  so  urgent  as  in  broncho-pneumonia  ;  a 
longer  historj^  of  illness  is  probable  and  also  a  history  of 
repeated  sweats.  The  girth  of  the  chest  is  increased  on  the 
affected  side  in  empyema  (unless  of  very  old  date,  in  which 
case  it  is  diminished),  and  sometimes  there  may  be  bulging  of 
the  intercostal  spaces. 


DISEASES   OF   THE    RESPIRATORY   TRACT      301 

The  differential  diagnosis  of  simple  from  tuberculous 
broncho-pneumonia  may  be  impossible  clinically  :  the  tuber- 
culous variety  is  often  more  insidious  in  onset,  and,  for 
a  time  at  least,  the  child  is  not  so  acutdy  ill  as  the  rapid 
extension  of  pulmonary  signs  might  appear  to  warrant,  and 
it  is  very  unusual  for  any  of  the  signs  to  clear  up,  even 
temporarily. 

The  sputum  should  be  examined  for  tubercle  bacilli,  and 
if  the  patient  is  too  young  to  spit  he  may  be  made  to  vomit  ; 
fragments  of  the  swallowed  sputum  may  then  be  picked  out 
of  the  stomach  contents  for  microscopical  investigation. 

XI.  ABSCESS  OF  THE  LUNG 

Two  varieties  of  pulmonar}'  abscess  may  be  met  with  : — 
First,  the  pysemic  abscess,  usually  small  and  multiple, 
depending  on  the  presence  of  an  infective  focus  in  the'right 
heart  or  in  a  systemic  vein ;  and  secondly,  a  single  lung 
abscess  vv'hich  may  occur  in  the  course  of  bronchiectasis, 
empyema,  unresolved  pneumonia,  broncho-pneumonia,  or 
tuberculosis  in  which  secondary  infection  has  taken  place  ; 
or  by  the  spread  of  infection  from  below  the  diaphragm, 
as  in  the  case  of  subphrenic  abscess  or  liver  abscess.  The 
embolic  forms  of  lung  abscess  are  especially  liable  to  be 
accompanied  by  empyema. 

The  diagnosis  of  Mihary  Pyaemic  Lung  Abscesses  is  usually 
impossible,  though  they  may  be  suspected  whenever  a 
septicaemia  results  from  right  heart  endocarditis  or  from 
septic  phlebitis  which  is  not  restricted  to  the  portal  system. 
Occasionally  a  septic  embolus  may  be  of  sufficient  size  to 
produce  a  lung  abscess  big  enough  to  cause  physical  signs. 
The  first  signs  in  such  a  case  will  be  those  of  infarction — viz., 
sudden  dyspnoea,  pain  in  the  chest,  pleurisy  and  cough. 
Ha-moptysis  may  follow  and  later  on  the  signs  of  lung  abscess 
as  mentioned  below. 

The  diagnosis  of  Single  Pulmonary  Abscess  will  (U])end  on 
the  combination  of  symptoms  of  sejjlic  poisoning  with  more 
or  less  indefinite  localising  signs  in  one  or  other  lung.  If  the 
abscess  communicates  with  a  bronchus  the  expectoration  of 
quantities  of  pus  will  help  the  diagnosis  ;  otherwise  the  signs 


302  MEDICAL  DIAGNOSIS 

are  likely  to  suggest  a  localised  empyema  or  even  an  area  of 
consolidation.  Exploratory  puncture  may  reveal  the  true 
state  of  affairs,  or  X-rays  may  enable  us  to  clear  up  the 
diagnosis. 

XII.  GANGRENE  OF  THE  LUNG. 

This  condition  is  produced  in  the  same  manner  as  is 
abscess  of  the  lung.  It  may  be  added  that  it  is  particularly 
likely  to  be  found  in  cases  of  diabetes  and  other  wasting 
disorders  of  metabolism. 

The  physical  signs  are  the  same  as  for  abscess,  but  the 
peculiar  odour  of  the  sputum  usually  leaves  no  room  for 
mistaken  diagnosis. 

In  both  gangrene  and  open  abscess,  examination  of  the 
sputum  will  show  shreds  of  elastic  tissue  produced  by 
disintegration  of  the  lung  substance  {vide  p.  03). 

XIII.  (EDEMA  OF  THE  LUNGS. 

This  may  occur  as  part  of  a  general  dropsy,  whether 
cardiac  or  renal,  in  debilitated  elderly  people  from  static 
causes  should  a  supine  position  be  enforced,  or  in  certain 
cases  of  mediastinal  tumour  in  which  the  pulmonary  circula- 
tion may  be  especially  embarrassed.  In  all  these  cases  the 
condition  is  of  gradual  development. 

Pulmonary  cedema  may,  in  rare  cases,  develop  quite 
acutely  and  be  the  cause  of  sudden  death  ;  the  patho- 
logy of  the  phenomenon  is  not  understood  beyond  that  it 
must  be  caused  by  some  reflex  vaso-motor  disturbance.  It 
is  more  frequent  in  women  than  men  and  has  more  than 
once  been  recorded  during  coitus. 

The  diagnosis  of  pulmonary  oedema  will  rest  on  the  general 
condition,  the  presence  of  profuse  watery  sputum,  and  sym- 
metrical areas  of  relative  dulness  at  the  bases  of  the  lungs 
over  which  a  poor  air  entry  is  combined  with  numerous 
fine,  crackling  rales. 

XIV.  BRONCHIAL  ASTHMA. 

This  affection  often  starts  in  cliildhood,  but  no  age  is 
immune  ;  it  is  always  accompanied  by  more  or  less  chronic 


DISEASES   OF  THE   RESPIRATORY   TRACT      303 

bronchitis  and  emphysema,  and  is  characterised  b}- paroxysms 
of  urgent  expiratory  dyspnoea  in  which  the  sufferer  leans 
forward  with  a  livid,  clammy  face  and  with  his  chest 
fixed  in  a  position  of  forced  inspiration.  After  a  time, 
varying  from  minutes  to  two  or  three  hours,  the  attack 
terminates  in  a  fit  of  coughing,  during  which  a  small  amount 
of  mucus,  often  in  the  form  of  pellets,  is  generally  coughed  up. 
Each  attack  is  usually  of  sudden  onset,  and  often  a  definite 
aura  is  described,  generally  of  a  psychic  nature. 

There  are  no  characteristic  phj^sical  signs,  but  bronchitis 
and  emphysema  are  invariable.  The  sputum  generally 
contains  the  colourless  octohedral  crystals  of  spermin 
phosphate  (Charcot-Leyden),  Curschmann's  spirals  which 
are  mucinous  casts  of  the  bronchioles,  and  a  number  of 
eosinophil  cells.  In  addition,  during  the  attack  there  is  a 
definite  eosinophilia  in  the  blood. 

The  attacks  of  asthma  are  most  frequent  at  night'  they 
may  occur  apart  from  any  discoverable  exciting  cause,  or 
they  may  be  induced  by  a  great  variety  of  apparently  incon- 
sequent factors,  such  as  a  heavy  meal,  the  wearing  of  flannel, 
sleeping  in  a  feather  bed,  various  smells,  etc.,  etc. 

Certain  organic  causes  should  always  be  investigated,  such 
as  the  presence  of  enlarged  tonsils  or  adenoids,  hyper- 
trophied  tiirbinal  bones  or  other  forms  of  nasal  obstruction, 
and  even  errors  of  refraction. 

As  a  general  rule  asthmatic  patients  have  fewer  attacks  in 
towns  than  in  the  country,  a  fact  which  can^be  explained  by 
the  irritating  effect  of  the  dust  of  various  plants  in  the 
country. 

Asthma  is  regarded  as  a  neurosis  ;  the  immediate  cause  is 
probably  hypera»mia  of  the  bronchial  mucosa  and  spasm  of 
the  br(jnchioles  themselves.  These  are  produced  reflexly  by 
some  such  cause  as  those  just  discussed. 

There  is  no  doubt  of  the  diagnosis  if  an  attack  can  be 
observed,  and  in  other  cases  the  history  is  sufficient. 

Certain  other  forms  of  asthma  are  described  and  must  not 
be  confounded  with  true  bronchial  asthma. 

T/njwir  Asllnnn.  A  coiidiliou  which  is  liable  to  cause 
sudden  death  in  infants  and  young  children.  It  is  produced 
by  the  presence  of  an  enlarged  or  unduly  persistent  thymus 


304  MEDICAL   DIAGNOSIS 

gland  which  may  cause  dyspnoea  from  pressure  on  the 
trachea,  on  the  great  vessels,  or  on  the  vago-sympathetic 
nervous  system.  There  is  a  further  possibility  that  the 
abnormal  persistence  of  a  functional  thymus  gland  after 
ten  or  twelve  years  (when  it  should  commence  to  atrophy) 
may  permit  the  circulation  of  certain  toxins  which  may  be 
deleterious  to  the  health  of  the  patient.  The  condition 
is  but  rarely  suspected  during  life. 

Cardiac  Asthma.  Paroxysmal  dyspnoea  may  be  a  notable 
symptom  in  patients  suffering  from  advanced  myocardial 
degeneration  or  heart  failure  secondary  to  valvular  disease. 
The  individual  attacks  may  closely  resemble  true  bronchial 
asthma,  but  examination  of  the  heart  should  prevent 
mistake. 

Renal  Asthma.  Paroxysmal  dyspnoea  is  often  seen  in 
patients  with  severe  renal  disease  ;  in  such  cases  it  may  be 
an  ursemic  phenomenon  or  it  may  indicate  a  failing  heart. 
Examination  of  the  urine  will  prevent  such  a  case  being 
mistaken  for  bronchial  asthma. 

XV.  PLEURISY. 

Pleurisy  may  be  primary  or  secondary,  dry  or  with  effusion, 
and  the  effusion  may  be  simple  or  purulent. 

Primary  pleurisies  may  be  produced  by  tuberculosis, 
rheumatism  or  new  growth.  It  is  important  to  remember 
that  the  great  majority  of  all  cases  are  tuberculous. 

Secondary  pleurisies  may  result  from  any  pulmonary 
affection  that  extends  to  the  surface  of  the  lung  and  so 
involves  the  pleura,  or  they  may  occur  in  the  course  of  a 
septiccemia  and  in  certain  constitutional  metabolic  disorders 
such  as  Bright's  disease.  They  may  be  secondary  to  some 
infection  below  the  diaphragm,  or  they  may  occur  i)i  the 
course  of  such  specific  infections  as  enteric  or  scarlet  fever. 
Again,  tuberculosis  is  probably  the  most  common  cause, 
though  pleuro-pneumonia  is  responsible  for  many  cases. 

(i.)  Dry  Pleurisy. — The  symptoms  of  dry  pleurisy  are 
a  sudden  sharp,  stabbing  pain  in  the  chest  (which  is  greatly 
aggravated  by  drawing  a  deep  breath  or  by  coughing)  a  dry, 
hacking,  unproductive  cough,  and  a  sense  of  general  malaise. 


DISEASES   OF   THE    RESPIRATORY   TRACT      305 

There  is  usually  a  moderate  pyrexia  Avhicli  shows  a  distinct 
morning  remission. 

Examination  of  the  thorax  will  show  a  relative  immobility 
of  one  side  of  the  chest,  caused  by  the  instinctive  desire  to 
avoid  the  pain  of  movement. 

Auscultation  will  show  the  characteristic  to-and-fro  rub 
over  the  site  of  the  pleurisy  ;  this  rub  may  be  coarse  or  fine — 
it  sounds  rather  like  two  pieces  of  damp  leather  being  rubbed 
together  when  coarse,  and  like  hair  being  rubbed  between 
the  fingers  when  of  the  fine  variety.  It  is  audible  during  both 
inspiration  and  expiration  and  it  does  not  disappear  or  alter 
after  coughing.  The  deeper  the  respiration  the  more  audible 
the  rub. 

Pleuritic  friction  may  be  heard  over  any  part  of  the  chest ; 
it  is  most  frequently  detected  in  the  posterior  part  of  the 
axilla. 

It  is  important  to  remember  that  the  pain  of  pleurfsy  is 
often  referred  along  the  course  of  the  intercostal  nerves  even 
to  the  abdomen,  and  is  not  always  situated  at  the  site  of 
the  inflamed  portion  of  the  pleura. 

Diagnosis.  When  there  is  a  well-marked  rub  the  diagnosis 
of  dry  pleurisy  is  simple  enough,  but  the  rub  is  often 
evanescent,  and  the  case  may  not  be  seen  till  the  rub  has 
gone  and  the  pain  also.  Under  such  circumstances  the 
description  of  the  pain  may  be  all  there  is  to  go  upon.  If 
the  patient  is  known  to  be  suffering  from  some  pulmonary 
disease,  such  as  tuberculosis,  in  which  pleurisy  is  common,  an 
additional  j)robability  is  present.  In  some  cases  the  friction 
disappears  quickly  because  the  two  layers  of  pleura  become 
separated  by  a  thin  layer  of  fluid  ;  as  this  fluid  is  absorbed 
the  rub  may  ro-appear. 

Dry  pleurisy  juiist  be  differentiated  from  pleurodynia  or 
intercostal  myalgia,  in  whicii.  of  course,  there  is  never  any 
rub  or  true  im])airMU'iil  of  air  entry,  whik'  the  pain  tends  to 
hv  more  boring  or  aciiing  than  siiarj)  and  stabbing,  and  there 
is  no  constitutional  disturbance.  Both  these  conditions  are 
associated  with  local  tenderness  to  a  greater  extent  and  more 
commonly  tiuui  ])U'nrisy. 

Jntra-pulmonary  scnindi^  (fine  r^les)  or  creaky  rhonchi  niay 
be  mistaken  for  ])leuritic  friction,  especially  at  the  fringes 
M.D.  20 


306  MEDICAL   DIAGNOSIS 

of  the  lungs  ;  they  can,  however,  nearly  always  be  greatly 
modified  by  coughing  and  deep  breathing,  while  they  are 
often  confined  to  the  inspiratory  part  of  the  respiratory 
cycle. 

Pericarditis  may  be  mistaken  for  pleuro-pericarditis  or 
inflammation  of  that  part  of  the  pleura  which  lies  on  the 
pericardium.    The  differences  have  been  considered  on  p.  260. 

The  pain  of  pleurisy,  especially  of  diaphragmatic  pleurisy, 
is  of  ten  referred  to  the  abdomen,  and  an  acute  abdominal 
condition  may  be  simulated.  A  careful  examination  will 
nearly  always  show  some  abnormality  of  the  thoracic  action 
or  physical  signs  which  will  suggest  that  the  trouble  is 
above  the  diaphragm,  while  there  is  no  true  immobility, 
tenderness,  or  rigidity  of  the  abdominal  wall. 

(ii.)  Simple  Pleural  Effusion.  The  symptoms  of  this 
condition  depend  rather  on  the  rapidity  with  which  the 
effusion  has  collected.  The  more  rapid  the  effusion  the  more 
marked  will  be  the  breathlessness  and  general  discomfort, 
while  if  the  fluid  has  been  poured  out  very  slowly,  a  large 
amount  may  be  present  without  marked  dyspnoea.  The 
characteristic  pain  of  the  dry  stage  of  the  pleurisy  disappears 
with  the  onset  of  effusion.  There  need  be  no  pyrexia,  but 
there  is  usually  a  shghtly  accelerated  respiration  rate. 

The  Classical  Signs  of  free  fluid  in  the  pleura  are  : — 

(1)  Impaired  mobility  of  the  affected  side. 

(2)  Displacement  of  the  heart  to  the  sound  side. 

(3)  Absolute  dulness  to  percussion  below  a  certain 
level. 

(4)  A  skodaic  or  "  boxy  "  percussion  note  above  the 
level  of  the  fluid  (this  is  usually  absent  in  large  effu- 
sions). 

(5)  Cutting  off  or  great  diminution  in  breath  sounds, 
voice  sounds,  and  tactile  fremitus  over  the  area  of  dulness. 

(6)  A  band  of  segophony  at  the  upper  level  of  the 
fluid. 

(7)  The  upper  level  of  the  dull  area  is  not  horizontal, 
but  forms  a  definite  curve  (Damoiseau's  curve)  as  is  shown 
in  Fig.  51. 

(8)  An  increased  measurement  on  the  side  of  the 
effusion. 


DISEASES    OF  THE   RESPIRATORY  TRACT      307 

In  addition  to  the  above  the  following  may  be  noted  in 
certain  cases  : — 

(1)  Bulging  of  the  intercostal  spaces  on  the  aifected 
side  when  there  is  much  fluid. 

(2)  Immobility  of  the  diaphragm  and  opacity  of  the 
lower  thorax,  as  shown  by  X-rays. 

(3)  Downward  displacement  of  the  liver  or  spleen, 
according  to  which  side  is  affected. 

(4)  A  small  area  of  tubular  breathing  about  the  upper 
level  of  the  fluid  behind,  depending  on  collapsed  lung. 

(5)  Grocco's  triangle.  This  is  a  triangle  of  dulness  on 
the  sound  side  formed  by  joining  that  vertebral  spine 
which  is  opposite  the  upper  limit  of  the  fluid  with  a  point 
8  cm.  from  the  middle  line  along  the  twelfth  rib.  The 
remaining  sides  of  the  triangle  are  the  twelfth  rib  and  the 
mid-line  behind.  , 

(6)  Dilatation  of  the  pupil  on  the  affected  side  from 
irritation  of  the  sympathetic  nerve  by  distension  of  the 
pleura  (this  is  a  rare  sign  and  is  more  commonly  met 
with  in  empyema). 

It  is  well  to  remember  that  fluid  in  the  pleura  does  not 
cause  a  positive  pressure  until  it  is  as  high  as  the  third  rib, 
and  that,  in  an  average  man,  this  is  equivalent  to  the 
presence  of  about  three  pints  of  fluid. 

Change  in  posture  may  cause  a  trifling  alteration  in  the 
shape  and  position  of  the  dull  area,  especially  when  the 
effusion  is  not  large. 

Difficulty  in  diagnosis  may  occur  when  the  effusion  is 
small  and,  as  sometimes  happens,  spread  out  into  a  thin 
layer.     In  all  cases  the  most  important  signs  are  : — 

(1)  The  displacement  of  the  heart. 

(2)  The  peculiar  dead,  woolly  percussion  note. 

(3)  Diminution  in  breath  sounds,  voice  sounds,  and 
fremitus. 

(4)  .^gophony. 

In  rare  cases  a  non-purulent  effusion  may  be  loculated  ; 
the  ])hysical  signs  may  then  be  rather  anomalous — for 
example,  the  dulness  may  be  strictly  localised  and  not  at 
the  extreme  base  of  the  lung,  while  there  will  often  be  much 
more  diffuse  tubular  breathing  than  is  ordinarily  heard. 

20—2 


308  MEDICAL  DIAGNOSIS 

Much  more  commonly,  however,  a  loculated  effusion 
will  be  found  to  be  purulent  {vide  next  section). 

The  differential  diagnosis  of  pleural  effusion  from  solid 
lung  and  from  pneumo-thorax  are  considered  on  pp.  52 
and  313  respectively. 

Collapsed  lung  may  simulate  an  effusion,  but  the  heart, 
if  displaced  at  all,  is  moved  towards  the  affected  side  ;  the 
intercostal  spaces  tend  to  show  inspiratory  recession, 
the  percussion  note  is  not  so  flat  as  in  effusion,  while  the 
auscultatory  signs  may  vary  from  complete  absence  of 
breath  sounds  to  loud  tubular  breathing,  and  adventitious 
sounds  (rdles  and  crepitations)  are  often  heard  so  long  as 
any  aeration  of  lung  persists. 

Further,  some  cause  for  possible  collapse  may  be  evident, 
such  as  mediastinal  tumour,  deformity  of  the  chest,  an 
extremely  debilitated  condition,  rickets,  broncho-pneumonia, 
or  bronchial  obstruction. 

Hydrothorax  gives  the  same  physical  signs  as  does  pleural 
effusion  ;  it  is  commonly  first  seen  on  the  right  side,  a  fact 
which  may  be  explained  by  the  anatomy  of  the  vena  azygos 
major,  and  tends  to  become  bilateral. 

Hydrothorax  may  be  anticipated  in  cases  of  right  heart 
insufficiency,  where  there  is  any  mechanical  obstruction 
to  the  venous  return  within  the  thorax,  as  in  new  growth, 
lymphadenoma,  etc.,  and  in  chronic  parenchymatous 
nephritis  as  a  part  of  the  general  oedema. 

(iii.)  Empyema.  In  addition  to  the  general  signs  of  pleural 
effusion  empyema  may  be  expected  to  present  some  of  the 
following  features  : — 

(1)  Toxic  appearance,  with  irregular  temperature,  rapid 
pulse  and  respirations,  and  tendency  to  free  perspira- 
tions. 

(2)  A  definite  leucocytosis,  usually  about  18,000  per 
cubic  millimetre. 

(3)  A  history  of  some  antecedent  illness,  such  as 
pneumonia  or  broncho-pneumonia. 

(4)  A  more  extensive  area  of  tubular  breathing  than 
is  usual  in  simple  effusion. 

(5)  The  absence  of  a  typical  Damoiseau's  curve,  owing 
to  the  tendency  for  the  formation  of  adhesions. 


DISEASES   OF   THE   RESPIRATORY   TRACT      309 

(6)  Possibly  some  oedema  of  chest  wall  on  the  affected 

side. 

The  possibility  of  an  empyema  being  loculated  should 
always  be  remembered,  and  to  this  end  careful  examination 
must  be  made  along  the  interlobar  septa  whenever  empyema 
is  suspected,  for  it  not  infrequently  happens  that  an  empyema 
is  formed  between  the  lobes  of  the  lung.  The  adjacent  lung 
substance  is  readily  compressed,  but  the  pus  itself  may 
remain  at  some  distance  from  the  chest  wall.  A  patch 
of  dulness  and  a  variable  amount  of  tubular  breathing  may 
be  the  only  physical  signs,  but  the  fact  that  these  are  found 
along  the  course  of  the  interlobar  septum  is  suggestive  of 
empyema  when  the  corroborative  symptoms  of  septic 
absorption  are  present. 

Paracentesis  Thoracis.  In  the  majority  of  cases  it  is 
possible  to  be  sure  of  the  presence  or  ab.sence  of  fl«id  in  a 
pleural  cavity  by  a  careful  consideration  of  the  signs  and 
symptoms  ;  occasionally,  however,  the  signs  may  be  so 
anomalous  that  the  diagnosis  can  only  be  settled  by  explora- 
tion with  a  needle.  This  manoeuvre  is  practically  free  from 
risk,  and  should  certainly  be  adopted  when  there  is  any  possi- 
bilitj''  of  the  effusion  being  purulent. 

The  best  instrument  is  a  stout  hollow  needle  attached  to 
a  syringe  of  at  least  20  c.c.  capacity  ;  or,  if  preferred,  a 
Potain's  aspirator  may  be  employed. 

For  diagnostic  purposes  the  site  of  election  is  the  point 
of  maximum  dulness,  always  provided  that  the  situation  of 
the  heart,  liver,  spleen,  and  stomach  are  borne  in  mind. 

As  a  general  rule,  when  the  fluid  is  free,  exploration  is  best 
performed  in  the  seventh  or  eight  spaces  in  or  just  behind 
the  line  of  the  .scapular  angle  ;  .some  authorities  advise 
the  sixth  space  in  the  mid-axillary  line. 

Where  pus  is  su.spected  and  the  signs  suggest  that  it  i.s 
loculated.  one  must  be  guided  entirely  by  the  situation  of 
the  dulness  and  tlie  tubular  breathing,  if  any  bo  ])resent. 

The  best  method  of  performing  paracentesis  is  to  have  the 
])atient  sitting  up,  or,  if  he  is  too  ill  to  sit  up.  lying  on  the 
sound  side  with  his  arm  raised  and  his  hand  on  the  opposite 
shoulder.  The  left  thumb -nail  is  then  placed  on  the  upper  edge 
of  the  rib  next  below  the  point  where  exploration  is  indicated 


310  MEDICAL  DIAGNOSIS 

and  the  needle,  attached  to  the  sj^ringe  and  guarded  about 
one  inch  from  its  point  by  the  right  forefinger,  thrust  swiftly 
along  the  thumb-nail  and  through  the  intercostal  space  into 
the  thorax  until  stopped  by  the  right  forefinger.  The  needle 
is  now  thrust  slowly  forwards — as  nearly  as  possible  at  right 
angles  to  the  thoracic  parietes — at  the  same  time  as  the 
piston  is  slowly  withdrawn  to  create  a  negative  pressure  in 
the  barrel  of  the  syringe. 

As  soon  as  pus  or  fluid  is  reached  it  will  appear  in  the 
syringe. 

The  first  syringe-full  should  be  placed  in  a  sterile  vessel 
for  subsequent  examination. 

It  is  essential  that  the  operation  of  paracentesis  should 
be  performed  with  all  antiseptic  precautions. 

Examination  of  the  fluid  withdrawn  should  be  directed 
to  the  following  points  :-— 

(1)  The  presence  of  organisms,  and,  if  present,  their 
nature  and  whether  they  are  alive. 

In  the  great  majority  of  cases  the  presence  of  bacteria  is 
an  indication  for  prompt  resection  of  rib  with  free  drainage, 
but  occasionally  it  may  happen  that  only  dead  pneumococci 
are  found  ;  under  these  circumstances  aspiration  of  the  fluid 
may  be  all  that  is  necessary,  though  in  our  opinion  it  is  better 
for  such  cases  to  be  drained. 

(2)  The  presence  of  cells  and  their  nature. 

In  ernjjyeina  the  great  majority  of  the  cells  are  pus  cells 
or  polymorphonuclear  leucocytes. 

In  sirnple  pleurisy  with  effusion  (tuberculous)  the  majority 
of  the  cells  are  lymphocytes,  though  a  certain  number  of 
uni-nuclear  endothelial  cells  are  usually  present. 

In  passive  exiidates  the  number  of  endothelial  cells  is 
increased  and  many  of  them  are  likely  to  be  disintegrating 
and  showing  fatty  degeneration. 

In  neiv  gronih  fragments  of  growth  may  be  seen.  Blood- 
cells  are  connnonly  present  and  large  multi -nucleate  endo- 
thelial cells  are  not  infrequent,  in  varying  stages  of  degenera- 
tion, if  the  examination  is  made  immediately.  Rivalta's  test 
is  a  simple  method  of  estimating  whether  an  effusion  is 
passive  or  inflammatory  :  about  half  a  drachm  of  effusion 
is  thrown  into  a  good-sized  beaker  containing  very  dilute 


DISEASES  OF  THE   RESPIRATORY  TRACT      311 

acetic  acid  ;  a  whdte  cloud  is  formed  by  inflammatory 
eflhision,  but  not  by  passive  exudates. 

It  is  a  safe  rule  that  all  primary  lymphocytic  effusions  are 
tuberculous  in  origin,  though  a  very  small  proportion  may  be 
due  to  other  causes,  such  as  rheumatism,  gonorrhoea,  etc. 

Unfortunately  the  proof  of  this  hypothesis  is  not  easy,  for 
the  reason  that  tubercle  bacilli  are  but  rarely  demonstrable 
in  the  aspirated  fluid.  When  they  are  present  it  is  a  curious 
fact  that  a  large  proportion  of  the  cells  present  are  frequently 
polymorphonuclear  leucocytes. 

A  better  method  of  proving  the  nature  of  a  given  pleural 
effusion  is  to  inject  a  considerable  quantity  of  the  fluid  into 
the  peritoneum  of  a  healthy  rabbit.  If  the  rabbit  develops 
glandular  and  splenic  tuberculosis  in  eight  weeks,  the  effusion 
was  tuberculous. 

Another  proceeding  of  value  is  to  compare  the  opsonic 
indices  for  tuberculosis  of  the  patient's  blood  serum,  Known 
healthy  blood  serum,  and  the  effusion.  It  is  suggestive  of 
tuberculosis  if  the  reading  of  the  effusion  varies  40  per  cent, 
from  that  of  the  patient's  blood  serum,  while  a  wide  difference 
between  the  two  blood  serums  is  also  suspicious.  A  tubercu- 
lous effusion  commonly  gives  a  much  lower  reading  than  the 
patient's  blood  serum. 

XVI.  PNEUMOTHORAX. 

The  causes  of  pneumothorax  are  as  follows  : — 
(i.)  Pulmonary  tuberculosis, 
(ii.)  Ulceration  of  an  empyema  into  the  lung, 
(iii.)  Rupture  of  a  lung  abscess  into  the  pleura, 
(iv.)  Rupture  of  an  emphysematous  bulla, 
(v.)  Trauma  of  the  chest,  such  as  a  fractured  rib  driven 
into  the  lung,  stab  wounds,  or  exploratory  paracentesis, 
(vi.)  Gastro-  or  intestino-  ])l(Miral  fistula, 
(vii.)  Whooping-cough. 
The  vast  majority  of  all  cases  are  tuberculous. 

Tlu'  ])iu'unu)tli()rax  may  be  produced  suddenly  or  tlic  air 
may  leak  in  gradually  ;  in  some  ca.ses  there  is  valvular  com- 
munication into  the  pleural  cavity,  which  may  get  more  and 
more  distended  with  each  inspiration  until  it  is  as  tigiit  as  a 
drum. 


312  MEDICAL   DIAGNOSIS 

In  all  open  cases  the  air  in  the  pleura  is  at  the  atmospheric 
pressure,  but  in  closed  cases  the  pressure  varies  greatly, 
usually  being  about  7  mm.  of  Hg.  (Osier).  This  is  of  course 
amply  sufficient  to  cause  complete  collapse  of  the  lung  on 
that  side,  as  the  normal  intra-pleural  pressure  is  not  more 
than  —  3  mm.  In  course  of  time  the  passage  into  the 
pleura  becomes  sealed  and  the  air  in  the  jDleura  is  absorbed, 
thus  permitting  re-expansion  of  the  lung.  Before  this 
happens,  however,  there  is  practically  always  a  pleural 
effusion  from  irritation  of  the  pleural  endothelium,  and 
often  this  effusion  becomes  purulent  from  infection  via  the 
communication  with  the  lung.  Thus  pneumothorax  usually 
develops  into  hydro-  or  pyo-  pneumothorax  in  a  compara- 
tively short  time. 

Symptoms.  At  the  moment  of  rupture  the  patient  often 
complains  that  something  has  "  given  way  "  in  the  chest  ; 
there  is  severe  pain  in  the  side,  cyanosis,  dyspnoea,  and 
shock.  A  person  who  is  cachectic  and  debilitated  may  well 
succumb  to  the  immediate  effects  of  pneumothorax,  but 
more  commonly  the  shock  and  pain  pass  off  in  a  few  hours 
and  only  a  varying  amount  of  dyspnoea  remains. 

It  may  very  exceptionally  happen  that  a  pneumothorax 
may  develop  so  insidiously  that  all  urgent  symptoms  are 
obviated. 

Physical  Signs.  The  affected  side  of  the  chest  is  immobile 
and  often  the  intercostal  spaces  bulge. 

The  heart  is  displaced  to  the  sound  side. 

The  percussion  note  is  usually  tympanitic  ;  if  the  air  is 
under  great  tension  the  note  is  so  high-pitched  as  to  be  dull, 
but  it  is  never  as  flat  as  when  fluid  is  present. 

Palpation  shows  complete  absence  of  tactile  fremitus. 

Auscultation  shows  great  enfeeblement  or  even  absence 
of  voice  and  breath  sounds,  and  a  characteristic  metallic 
tinkle  on  coughing  or  speaking  can  usually  be  detected. 

This  metallic  tinkle  can  often  be  beautifully  demonstrated 
by  using  one  coin  as  plessor  and  another  as  pleximeter  and 
simultaneously  listening  with  a  stethoscope  in  their  vicinity. 
The  noise  of  metalhc  contact  has  a  strikingly  clear  and  bell- 
like note,  and  is  known  as  the  coin  sound. 

When  fluid  is    present    (hydro-  or  pyo-  pneumothorax) 


DISEASES    OF   THE    RESPIRATORY   TRACT      313 

there  will  be  a  dull  note  at  the  base  of  the  lung  over  an  area 
the  upper  limit  of  which  is  readily  altered  by  change  of 
posture,  and  a  splash  will  be  heard  if  the  patient  sits  up  and 
his  chest  is  shaken.  This  splash  (succussion)  sound  may  be 
audible  at  some  distance,  but  should  be  listened  for  with 
a  stethoscope. 

Amphoric  breathing  may  be  heard  in  cases  of  open 
pneumothorax.  As  the  fluid  increases  the  air  grows  less 
and  eventually  only  a  bubble  remains,  and.  since  the  patient 
is  usually  kept  lying  down,  this  bubble  floats  up  to  the  front 
of  the  chest  and  can  often  be  mapped  out  as  a  resonant  area 
between  the  nipple  and  the  clavicle.  Gradually  this  resonant 
area  decreases  in  size  until  all  the  air  is  absorbed. 

Diagnosis.  From  the  foregoing  physical  signs  it  is  evi- 
dent that  the  diagnosis  of  a  large  pneumothorax  does  not 
present  much  difficulty.  A  greatly  pushed-over  heart  com- 
bined with  tympanitic  percussion  note  and  a  metallic  tinkle 
must  mean  pneumothorax. 

A  very  large  superficial  cavity  communicating  with  an 
open  bronchus  might  suggest  pneumothorax,  but  the  heart 
would,  if  moved  at  all,  be  drawn  towards  the  affected  side. 

A  diaphragmatic  hernia  may  present  difficulties  of  diag- 
nosis, as,  for  example,  when  the  stomach  is  situated  mostly 
in  the  thorax  owing  to  congenital  deficiency  of  part  of  the 
diaphragm.  It  will  be  noted  in  such  a  case  that  the 
ingestion  of  food  or  water  effects  a  profound  alteration  in 
the  percussion  note,  and  that  borborygmi  are  audible  inde- 
pendently of  movement.  An  X-ray  examination  after  a 
bismuth  meal  would  be  conclusive. 

Simple  pleural  effusion  may  be  simulated  in  those  cases 
where  the  tension  is  so  high  that  a  dull  note  is  heard  on  per- 
cussion. The  metallic  tinkle  and  the  relatively  great  dis- 
placement of  the  heart  will  suggest  the  true  diagnosis. 


CHAPTER   III 

DISEASES   OF    THE    MOUTH,   FAUCES,   CESOPHAGUS   AND 
ALIMENTARY  TRACT 

I.  THE  TONGUE  AND  MOUTH. 

(a)  The  Tongue.  The  tongue  is  an  index  of  the  well- 
being  of  the  stomach  and  intestines,  and  the  gastric  functions 
are  disturbed  reflexly  in  all  febrile  disorders  and  in  many 
other  conditions  of  ill-health. 

Normally  the  tongue  should  be  pink,  clean,  and  moist. 

In  chronic  gastritis  the  tongue  is  pale,  flabby,  covered 
with  fur,  and  indented  by  the  teeth. 

In  gastric  ulcer  unassociated  with  gastritis  the  tongue 
is  clean. 

In  chronic  constipation  the  tongue  is  thickly  coated 
and  the  fur  is  sometimes  yellowish  in  colour. 

In  thrush  the  tongue  may  be  covered  by  a  white  mould 
(oidium  albicans). 

In  fevers  the  tongue  is  dry  and  coated.  The  strawberry 
tongue  of  scarlet  fever  has  been  described  on  p.  62. 

In  enteric  fever  the  tongue  is  moist  in  the  early  days, 
with  a  slab  of  white  fur  on  each  side  of  the  mid-hne  and  a 
bright  red  line  at  each  lateral  margin  and  often  down  the 
centre  ;  in  the  later  stages,  as  in  any  prolonged  fever  with 
toxaemia  and  exhaustion,  the  tongue  is  dry  and  cracked. 

In  diabetes  the  tongue  is  large  and  beefy  in  appearance, 

In  chronic  alcoholism  and  in  general  paralysis  of  the  insane 
the  tongue  is  finely  tremulous. 

In  disseminated  sclerosis  and  in  chorea  there  is  a  coarse 
tremor  on  protrusion  of  the  tongue.  In  the  latter  disorder 
the  tongue,  instead  of  being  withdrawn  in  the  usual  manner, 
is  suddenly  snapped  back  into  the  mouth. 

In  cretins  the  tongue  is  too  big  for  the  mouth,  while  in 


DISEASES   OF   THE   ALIMENTARY   TRACT      315 

mongolian  idiots  it  shows  deep  longitudinal  fissures  on  its 
surface. 

In  most  cases  of  hemiplegia  the  tongue  is  protruded 
towards  the  side  of  the  paralj'sed  limbs  :  it  may  be  coated 
on  one  side  only. 

In  bulbar  j^^^ralysis  the  tongue  is  wasted,  shrivelled,  and 
cannot  be  protruded. 

In  facial  paralysis  there  is  loss  of  taste  for  the  anterior 
two-thiids  of  the  corresponding  half  of  the  tongue  provided 
that  the  lesion  of  the  nerve  is  situated  at  that  part  of  its 
course  wherein  it  is  accompanied  by  the  chorda  tympani 
nerve,  that  is  to  say  between  the  geniculate  ganglion  and  a 
point  about  \  inch  above  the  stylo-mastoid  foramen. 

Epilepsy  may  be  suggested  by  scarring  of  the  tongue. 

Naso-pharyngeal  disease,  adenoids,  mouth  breathing, 
dental  caries,  and  a  milk  diet  all  tend  to  cause  a  coated 
tongue.  ^ 

Syphilis  may  be  shown  either  by  gummatous  ulceration, 
fissured  scars,  or  the  dense,  white,  smooth,  raised,  non- 
ulcerated  though  sometimes  fissured  patches  of  leucoplakia. 
Similar  patches  may,  however,  be  caused  by  smoking,  spices, 
or  alcohol. 

Addison's  disease  may  cause  brown  pigmentation  of  the 
tongue. 

Epithelioma  must  not  be  mistaken  for  gumma.  A 
malignant  ulcer  usually  has  a  horny  edge  ;  infiltration  causes 
early  fixation  of  the  tongue,  and  glandular  involvement  is 
common  in  the  sub -maxillary  triangles. 

(I))  The  Gums  and  Cheeks.  Pyorrhoea  alveolaris  causes  a 
line  of  hy])ertemia  at  the  gum  margin,  while  pressure  will 
cause  pus  to  exude  from  between  the  gum  and  the  tooth. 
Slight  cases  can  only  be  detected  by  mo«t  laborious  examina- 
tion  of  each  tooth  socket  with  a  fine  ])rob(\  The  importance 
of  the  part  played  by  pyorrhoea  in  the  production  of  rheunui- 
toid  arthritis,  pernicious  anaemia,  and  obscure  toxaemia  is 
still  debated,  but  it  is  certain  that  it  can  produce  such  or 
similar  conditions,  and  even  septicaemia  has  been  initiated 
by  this  disease. 

Sloughing  gujus  with  gangn>nous  tonsillitis  are  highly 
suggestive  of  acute  lymphatic  leukaemia  or  aplastic  anaemia 


-316  MEDICAL  DIAGNOSIS 

when  they  occur  in  young  people.  In  older  persons  pernicious 
anaemia  is  more  probable.  In  the  absence  of  tonsillitis 
scurvy  must  be  considered,  as  well  as  purpura  hsemorrhagica 
and  chronic  mercurial  poisoning. 

Gangrenous  stomatitis  may  also  occur  in  children  after  the 
acute  exanthems  (especially  measles),  and  is  likely  to  be 
accompanied  or  followed  bj'  7wma  oris,  i.e.,  a  patch  of 
gangrene  starting  on  the  buccal  aspect  of  the  cheek,  which 
soon  involves  its  entire  thickness,  spreads  steadily,  and  is 
practically  always  attended  by  a  fatal  issue. 

Ulcerative  stomatitis  occurs  in  two  forms.  In  the  mild  or 
follicular  form  small  crops  of  vesicles  occur  on  the  lips, 
cheeks,  and  tongue  ;  these  break  and  small  circular  ulcers 
are  left.  Infants  and  young  children  are  the  principal 
sufferers  from  this  condition.  In  the  more  severe  form 
{fetid  stomatitis)  young  and  ill-cared-for  children  are  again 
chiefly  affected  ;  the  ulcers  are  larger  and  tend  to  spread  ; 
both  gums  and  cheeks  are  involved,  and,  for  a  few  days,  the 
constitutional  symptoms  are  severe. 

II.    THE  TONSILS. 

A.  Acute  Follicular  Tonsillitis.  The  onset  of  symptoms 
is  abrupt.  There  is  shivering  or  even  a  rigor,  with  a  sudden 
rise  of  temperature  to  from  102°  to  104°  N.  The  pulse  is 
full  and  bounding,  but  not  extremely  rapid.  The  face  is 
flushed,  the  eyes  are  bright,  but  there  is  no  circum-oral 
pallor.  Sometimes  a  patchy  erythema  may  appear  about 
the  limbs  or  trunk  ;  this  has  no  characteristic  features  and 
tends  to  fade  rapidly.  There  is  dysphagia  with  a  sense 
of  soreness  or  stiffness  down  the  neck,  and  the  submaxillary 
glands  become  enlarged.  Inspection  of  the  throat  will 
show  that  one  or  both  tonsils  are  enlarged  and  inflamed, 
while  yellowish-white  plugs  can  be  seen  projecting  from  the 
tonsillar  crypts.  Sometimes  the  secretion  from  the  crypts 
runs  together  in  the  form  of  a  localised  membrane,  which, 
however,  can  readily  be  removed  with  a  swab. 

This  condition  must  not  be  mistaken  for  diphtheria  {vide 
p.  14),  scarlet  fever  {vide  p.  65),  or  for  Vincent's  angina 
{vide  p.  14).     In  all  cases  a  swab  should  be  taken  for  bac- 


DISEASES   OF   THE   ALBIENTARY   TRACT      317 


teriological  examination.  A  mixed  growth  of  strepto-  and 
staphylo-  cocci  will  generally  be  obtained  from  a  case  of 
follicular  tonsillitis. 

B.  Acute  Parenchymatous  Tonsillitis.  The  symptoms  are 
identical  with  those  of  follicular  tonsilhtis,  but  this  form  is 
more  likely  to  be  associated 

with  acute  inflammation  of 
the  faucial  pillars  and 
pharynx  ;  it  is  u  s  u  a  1 1  y 
streptococcal  in  origin  and 
closely  resembles  faucial 
erysipelas. 

The  tonsils  are  enlarged 
and  dusky  red  in  colour. 
and  often  they  have  a 
rather  glazed  appearance. 
There  is  little  or  no  folli- 
cular exudate. 

The  constitutional  symp- 
toms are  similar  to  those 
of  follicular  inflammation, 
but  the  disease  is  more 
severe  and  has  a  longer 
course.  The  differential 
diagnosis  is  the  same. 

It  must  be  remembered 
that  this  form  of  tonsilhtis, 
even  more  than  the  folli- 
cular form,  is  likely  to  be 
a  manifestation  of  rheuma- 
tism. 

C.  Acute  Peritonsillar 
Inflammation  (Quinsy).  This  condition  tcnninates  in  the 
formation  of  an  absce.-s  behind  one  or  other  tonsil.  The 
onset  is  not  abrupt,  though  the  symptoms  become  severe  in 
from  twelve  to  thirty-six  hom-s.  At  the  outset  there  is 
increasing  pain  and  soreness  down  one  side  of  the  throat  ; 
soon  dysphagia  becomes  acute,  the  temperature  rises  to 
103''  to  104^,  and  a  lancinating  pain  suggests  that  pus 
formation  is  in  progress. 


1 

^^ 
1 

1 

1 

IC6' 
/OS' 
ItHf 
103° 
lOZ" 
101° 

IOC 

39° 
08' 
97° 
96° 
'.95° 
ItO 
130 
IZO 

no 
100 
90 
80 

70 

60 

'7  SO 

ss 

45 
35 

25 

M    E 

M   E 

M   E 

H  E 

M   E 

M  E 

ME 

M  E 

M  E 

: 

\\ 

■^ 

v^' 

: 

v^ 

i^ 

'■f\ 

V 

\j' 

^ 

; 

; 

v: 

lA 

"^" 

■-- 

.^. 

... 

... 

-T" 

y- 

:r- 

— - 

; 

; 

^\ 

v^ 

\'A 

./ 

■ 

V 

'^ 

V^ 

^: 

Fig.  53.— Chart  from  a  case  of  Folli- 
cular Tonsillitis.  Note  the  relative 
slowTicss  of  the  pulse  as  compared 
with  Dii)htheria  or  Scarlet  Fever. 


318  MEDICAL   DIAGNOSIS 

Examination  shows  an  inflamed  tonsil,  which  is  pushed 
forwards  and  towards  the  middle  line  by  a  red,  brawny, 
sometimes  oedematous  swelling  of  the  peritonsillar  tissues. 

The  faucial  aperture  may  be  well-nigh  obliterated, 
and  dyspnoea  may  be  alarming.  Eventually  fluctuation 
will  appear. 

After  several  days,  if  incision  be  withheld,  the  abscess 
bursts  into  the  mouth,  and  recovery  is  thenceforward  rapid, 
though  occasionally  the  cavity  fills  up  again  with  pus  owing 
to  imperfect  drainage.  Sometimes,  and  especially  if  the 
quinsy  bursts  during  sleep,  septic  pneumonia  or  even 
sudden  death  from  asphyxia  may  result. 

The  diagnosis  of  quinsy  presents  no  difficulty  ;  it  must 
not  be  confounded  with  retropharjmgeal  glandular  abscess, 
which  causes  a  bulge  on  the  posterior  pharyngeal  wall 
and  is  practically  limited  to  small  children,  or  with  retro- 
pharyngeal abscess  due  to  caries  of  the  cervical  spine,  which 
may  point  to  one  or  other  side  of  the  mid-hne  and  which 
can  usually  be  diagnosed  by  the  pain  caused  on  manipulating 
of  the  cervical  vertebrae. 

D.  Gangrenous  tonsillitis  may  occur  as  part  of  a  septi- 
csemic  infection,  in  acute  lymphatic  leukaemia,  in  purpura 
heemorrhagica,  in  aplastic  anaemia,  or  in  the  late  stages 
of  ordinary  pernicious  anaemia, 

III.    THE  PHARYNX. 

A.  Acute  pharyngitis  is  often  secondary  to  a  faucial  or 
nasal  infection,  as  in  rheumatism,  scarlet  fever  or  diphtheria, 
but  it  may  occur  primarily  as  an  acute  catarrhal  affection 
or  from  direct  irritation,  such  as  the  inhalation  of  noxious 
vapours.  The  constitutional  disturbance  is  but  slight  ; 
there  is  dysphagia  and  a  raw  or  sore  feeling  in  the  naso- 
pharj^nx. 

Inspection  shows  an  inflamed  mucosa,  which  is  sometimes 
coated  with  a  glairy  muco-purulent  discharge. 

It  should  be  remembered  that  recurrent  acute  pharyngitis 
is  probably  due  to  nasal  or  retro -nasal  trouble,  such  as 
adenoid  vegetations,  hypertrophied  turbinal  bones,  chronic 
rhinitis,  or  sinusitis. 


DISEASES   OF    THE    ALBIENTARY   TRACT      319 

B.  Chronic  pharyngitis  is  usually  the  result  of  too  much 
speaking  without  the  necessary  knowledge  of  how  to  use 
the  voice,  too  much  alcohol,  or  too  much  tobacco  ;  it  is 
also  likely  to  accompany  chronic  nasal  catarrh  or  chronic 
affections  of  the  nasal  sinuses. 

The  most  prominent  symptom  is  a  constant  "  hawking 
cough  "  with  a  perpetual  desire  to  "  clear  the  throat/' 

Chronic  laryngitis  is  a  fairly  common  accompaniment, 
and  in  these  circumstances  the  voice  may  be  husky  or  even 
lost.  Inspection  shows  that  the  pharyngeal  mucosa  is 
injected  :  prominent  venules  may  sometimes  be  observed 
on  it,  as  well  as  raised  red  patches  of  hypertrophied  lymph 
tissue . 

In  other  cases  the  chronic  irritation  causes  atrophy  of  the 
secreting  structures  and  a  smooth,  dry  surface  results. 

C.  Retropharyngeal  Abscess,  (i.)  Originating  in  lymph 
nodules  situated  in  front  of  the  prevertebral  fascia.  Pre- 
sumably this  infection  is  conveyed  through  the  posterior 
pharyngeal  wall.  These  abscesses  are  not  tuberculous,  and, 
except  in  traumatic  cases,  are  chiefly  met  with  in  infancy. 
The  symptoms  are  fever,  dj^sphagia,  and  dyspnoea,  for  which 
no  cause  can  be  found  in  the  lungs  or  heart.  Examination 
of  the  throat  may  show  a  rounded  swelling  bulging  from  the 
back  wall  of  the  pharynx  ;  sometimes  this  may  be  hidden 
by  the  soft  palate,  but  it  can  always  be  detected  by  the 
examining  finger.  The  abscess  nearly  always  points  at  or 
about  the  mid-hne. 

(ii.)  Originating  in  tuberculous  caries  of  the  upper 
cervical  vertehrce.  These  abscesses  commence  behind  the 
prevertebral  fascia  and  are  seen  in  older  children  than  the 
first  variety.  The  bulging  which  they  produce  is  lateral 
rather  than  central.  The  .symptoms  are  chronic  rather  than 
acute. 

The  tenderness  of  the  cervical  spine  with  fixation  of  the 
head  and  hectic  temperature  should  suggest  the  diagnosis. 

It  is  important  not  to  mistake  for  each  other  these  two 
varieties  of  retropharyngeal  abscess,  since  the  treatment  is 
different.  The  tuberculous  abscess  is  opened  externally 
behind  the  sterno-mastoid,  while  the  other  form  is  opened 
into  the  pharynx. 


320  MEDICAL   DIAGNOSIS 

IV.    THE  (ESOPHAGUS. 

A.  (Esophageal  Pouches.  These  may  be  congenital  or 
acquired  ;  they  are  usually  situated  at  the  upper  end  of 
the  oesophagus  about  the  level  of  the  cricoid  cartilage  or 
else  at  the  level  of  the  tracheal  bifurcation. 

They  may  give  rise  to  no  symptoms,  but  food  may  be 
caught  up  in  them,  giving  rise  to  choking  sensations,  dys- 
phagia, and  retching. 

They  cannot  readily  be  diagnosed  except  with  the  X-rays 
after  a  bismuth  meal,  or  by  the  passage  of  an  oesophageal 
bougie. 

B.  (Esophageal  Varix.  A  sudden  profuse  hsematemesis 
in  a  cirrhotic  individual  who  has  no  history  suggesting 
gastric  ulcer  may  lead  to  a  correct  diagnosis,  especially 
if  the  blood  is  bright  red.  It  must  be  remembered  that 
rupture  of  an  oesophageal  pile  is  often  followed  by  collapse 
and  death  without  hsematemesis  ;  in  such  cases  a  complete 
blood-cast  of  the  stomach  is  found  post  mortem. 

Unless  an  oesophageal  varix  leaks,  there  are  no  signs  or 
symptoms  to  suggest  its  presence. 

C.  (Esophageal  Obstruction.  This  may  be  produced  by 
stenosis  after  ulceration,  which  may  be  simple  (as  from  the 
swallowing  of  some  corrosive),  syphilitic,  or  malignant. 
The  gullet  may  also  be  obstructed  by  pressure  from  without 
as  by  an  aneurysm  or  a  mediastinal  tumour,  or  there  may 
be  impaction  of  some  foreign  body,  such  as  a  halfpenny  or  a 
collar-stud,  in  the  lumen  of  the  tube.  Such  foreign  bodies 
are  usually  impacted  {a)  at  the  level  of  the  cricoid,  (6)  oppo- 
site the  tracheal  bifurcation,  or  (c)  at  the  cardiac  opening 
of  the  stomach. 

The  chief  symptom  of  oesophageal  obstruction  is  progres- 
sive difficulty  in  swallowing  solids.  Fluids  are  generally  taken 
without  discomfort  till  a  considerably  later  date.  The  usual 
description  given  is  that  the  food  seems  to  stick  at  a  certain 
point  (most  often  referred  to  the  episternal  notch).  Violent 
retching  is  immediately  initiated  and  the  food  is  returned, 
often  accompanied  by  a  white  frothy  fluid.  Wasting  is 
always  rapid,  more  so  in  mahgru\nt  cases,  in  which  cachexia 
is  added  to  simple  starvation. 


DISEASES   OF  THE  ALIMENTARY  TRACT      321 

In  making  a  differential  diagnosis  the  following  points 
should  be  borne  in  mind  : — 

(i.)  After  the  age  of  30  years  80  per  cent,  of  all  cases  of 
oesophageal  obstruction  are  malignant.  The  presence  of 
enlarged  glands  above  the  clavicles  indicates  a  new  growth 
with  certainty. 

(ii.)  In  children  the  commonest  causes  are  impaction  of  a 
foreign  body,  swallowing  a  corrosive,  or  diphtheritic  oesopha- 
gitis. Inquiry  will  generally  elicit  the  fact  that  something 
may  have  been  swallowed  (this  should  be  confirmed  by  the 
X-rays).  Inspection  of  the  fauces  will  show  burning  from 
corrosive,  and  probably  membranous  inflammation  in 
diphtheritic  cases. 

(iii.)  In  young  ivomen  hysterical  spasm  may  closely 
simulate  organic  obstruction.  Other  signs  of  hysteria  may 
nearly  always  be  found,  such  as  hemi-ansesthesia,''  mono- 
plegia, aphonia,  etc. 

Anorexia  nervosa  is  usually  seen  in  young  women,  and 
immediate  vomiting  or  regurgitation  of  all  solid  food  is  a 
fairly  constant  symptom  of  this  condition.  There  is,  how- 
ever, no  true  obstruction  and  the  food  passes  without  delay 
into  the  stomach.  This  can  be  demonstrated  readily  by 
means  of  the  X-rays  and  food  impregnated  with  bismuth 
{vide  also  p.  588). 

(iv.)  Aneurysm  and  mediastinal  tumour  commonly  give 
their  own  characteristic  signs  {vide  p,  269).  Farther, 
pressure  from  these  causes  is  but  rarely  sufficient  to  cause 
such  definite  obstruction  as  does  organic  stenosis  ;  indeed, 
an  aortic  aneurysm  not  infrequently  causes  death  by 
ulcerating  into  the  oesophagus  without  ever  causing  clinical 
obstruction. 

(v.)  Syphilis  must  always  be  remembered,  though  it  is  a 
very  uncommon  cause  of  oesophageal  obstruction.  If  the 
Wassermann  reaction  is  positive  the  exhibition  of  anti- 
syphilitic  treatment  is  justified.  In  any  case  a  course  of 
potassium  iodide  may  cause  temporary  improvement. 

(vi.)  The  passage  of  oesophageal  bougies  will  at  once  show 
the  presence  of  oesophageal  obstruction.  It  is,  however, 
not  justifiable  to  use  these  instruments  as  a  means  of  diag- 
nosis unless  there  is  suspicion  amounting  practically  to  cer- 

M.D.  21 


322  MEDICAL   DIAGNOSIS 

tainty  that  the  case  is  hysterical.  There  is  a  verj^  grave  risk 
of  passing  a  bougie  through  the  wall  of  an  aneurysm,  through 
the  floor  of  an  epitheliomatous  ulcer,  or  through  an  oeso- 
phageal diverticulum,  and  the  results  of  such  a  proceeding 
may  well  prove  disastrous.  If  it  is  considered  desirable  to 
pass  an  oesophageal  bougie  the  following  technique  may  be 
adopted  : — 

Sit  the  patient  up  in  a  hard  chair  and  direct  him  to  extend 
his  head  as  much  as  he  can  with  comfort.  Instruct  him  to 
open  his  mouth  and  to  breathe  steadily,  deeply,  and  per- 
sistently through  the  nose.  Now,  having  smeared  the 
bougie  with  glycerine,  pass  it,  unaided  by  a  finger  in  the 
mouth,  boldly  down  the  posterior  pharyngeal  wall.  The 
patient  should  be  instructed  to  swallow  as  the  instrument 
touches  the  wall  of  the  pharynx.  A  slight  obstruction  will 
be  noticed  as  the  point  enters  the  oesophagus  at  the  level 
of  the  cricoid  cartilage.  Hysterical  spasm  will  produce  a 
temporary  obstruction.  Organic  obstruction  produces  a 
'permanent  obstruction,  the  level  of  which  can  be  estimated  by 
noticing  the  distance  the  bougie  has  passed  from  the  patient's 
front  teeth.     Force  should  never  be  used. 

(vii.)  If  a  semi-solid  bolus  of  bismuth  and  oatmeal  be 
swallowed,  its  course  can  be  followed  with  a  fluoroscopic 
screen,  and  any  delay  or  obstruction  can  be  accurately  noted 
as  well  as  the  position  where  this  occurs. 

This  method  is  more  informative  and  vastly  safer  than  the 
use  of  a  bougie. 

(viii.)  Epithelioma  of  the  oesophagus  is  most  common  at 
the  level  of  the  tracheal  bifurcation,  next  at  the  cardiac 
orifice,  and  lastly  at  the  level  of  the  cricoid  cartilage. 

V.    THE  STOMACH. 

{a)  Preliminary  Remarks.  At  birth  the  capacity  of  the 
stomach  is  only  1  oz.  to  1|  oz.  ;  in  the  adult  it  is  from 
2  to  3  pints. 

The  position  of  the  stomach  is  variable,  since  there  is  only 
one  fixed  point,  the  cardiac  orifice,  which  is  situated  1  inch 
to  the  left  of  the  sternum  along  the  seventh  costal  cartilage. 

The  pylorus  should  be  about  2  inches  above  and  1  inch 


DISEASES   OF   THE   ALIMENTARY  TRACT      323 

to  the  right  of  the  umbilicus,  that  is  to  say,  1  inch  to  the 
right  of  the  mid-point  of  the  line  joining  the  episternal 
notch  to  the  pubic  symphysis. 

The  lesser  curvature  of  the  stomach  is  nearly  vertical  and 
its  long  axis  is  about  20"  removed  from  the' vertical.  The 
fundus  occupies  a  considerable  part  of  the  left  '"  bed  ""  of  the 
diaphragm  and  extends  as  high  as  the  fifth  intercostal  space 
in  the  mid-clavicular  line,  while  to  the  left  it  is  in  contact 
with  the  spleen. 

The  lower  level  of  the  greater  curvature  of  the  stomach 
does  not  quite  reach  the  transver.se  plane  of  the  umbilicus 
in  health. 

(b)  Physical  Examination  of  the  Stomach.  Inspection 
shows  no  evidence  of  a  healthy  stomach.  A  dilated  stomach 
may  be  apparent  as  a  definite  bulge  with  stomach  outline 
in  the  epigastrium  and  left  hypochondrium.  If  the  dilata- 
tion is  due  to  pyloric  obstruction,  peristalsis  may  be  visible 
from  left  to  right.  Rarely  reverse  peristalsis  may  be 
detected  ;  when  present  this  is  pathognomonic  of  organic 
obstruction.  It  is  perhaps  most  often  seen  in  congenital 
hypertrophic  stenosis  of  the  pylorus. 

Peristalsis  maybe  elicited  sometimes  (but  not  in  health)  by 
tapping  and  light  "  dipping  "  with  the  pulp  of  the  fingers  in 
the  left  hypochondrium. 

Certain  tumours,  especially  of  the  pylorus,  may  be  visible 
and  may  be  observed  to  move  with  respiration. 

Palpation  may  reveal  the  presence  of  a  tumour,  which  may 
be  hard  or  soft,  fixed  or  mobile. 

Pyloric  tumours  are  the  ones  most  easily  felt,  and  until 
adhesions  are  formed  which  bind  them  to  the  liver  and  other 
neighbouring  vi.'^cera  they  are  freely  moveable  both  on  respira- 
tion and  manipulation. 

Palpation  also  shows  whether  there  is  any  tenderness 
or  not.  The  size  and  position  of  any  tender  area  should 
be  estabH.shed. 

In  chronic  gastritis  there  is  slight  diffuse  tenderness  in 
the  epigastrium,  sometimes  with  an  area  of  maximum 
intensity  about  H  inches  below  the  xiphoid. 

In  gastric  ulcer  there  is  often  a  very  small  area  of  acute 
tenderness  just  to  one  side  or  other  (usually  the  left)  of 

21—2 


324  MEDICAL  DIAGNOSIS 

the  mid-line  about  2  inches  above  the  umbihcus,  but 
the  points  of  tenderness  are  necessarily  very  variable,  as  the 
ulcers  may  be  situated  anywhere. 

In  examining  for  gastric  tenderness  palpation  should 
be  very  light  and  performed  with  the  pulps  of  the  fingers 
and  with  loarm  hands. 

Cutaneous  hypersesthesia  is  often  very  marked  to  the  left 
of  the  mid-line  in  cases  of  gastric  ulcer. 

Succussion  (stomach-splash)  is  elicited  by  placing  the 
palm  of  the  left  hand  over  the  left  lower  ribs  behind  and 
jolting  smartly  with  the  flat  of  the  right  fingers  in  the  left 
hypochondrium.  Succussion  is  a  confirmatory  sign  of 
gastric  dilatation,  but  is  only  of  value  in  conjunction  with 
other  signs  and  when  it  is  elicited  at  times  when  the 
stomach  should  be  empty,  that  is  to  say,  six  or  more 
hours  after  a  meal. 

Percussion.  The  stomach  note  varies  greatly  with  the 
amount  of  gas  in  the  organ.  When  gas  is  present  the  note 
is  very  tympanitic,  even  more  so  than  that  over  the  dis- 
tended colon.  When  the  stomach  is  quite  empty  of  gas 
(which  but  rarely  happens)  the  note  is  dull,  and  under  these 
conditions  inflation  must  be  practised  before  percussion 
can  be  of  value. 

A  glass  of  soda-water  is  often  sufficient  to  distend  the 
stomach,  but  a  surer  method  is  to  administer  haK  a  drachm 
of  sodium  bicarbonate  dissolved  in  a  Uttle  water  followed 
immediately  by  a  like  amount  of  tartaric  acid.  Perhaps 
the  best  method  is  to  pass  a  gastric  tube  to  which  a 
pump  is  attached  and  gently  to  inflate  the  viscus  by  this 
means. 

Even  with  an  inflated  stomach  ordinary  percussion 
is  not  reliable,  but  auscultatory  percussion  may  be  of 
great  value.  To  perform  auscultatory  percussion  the  chest 
piece  of  the  stethoscope  is  placed  over  a  piece  of  undoubted 
stomach,  say  2  inches  below  and  to  the  left  of  the  xiphi- 
sternum  :  using  this  as  a  centre  light  percussion  is  made 
along  lines  radiating  from  it  and  that  point  noted  on  each 
line  where  the  'pitch  of  the  note  changes  as  heard  through 
the  stethoscope.  The  lower  border  of  the  stomach  can  be 
mapped   out  with   considerable   accuracy  by   this   means. 


DISEASES   OF  THE   ALIMENTARY  TRACT      325 

Merely  drawing  the  finger  along  the  skin  radially  from  the 
bell  of  the  stethoscope  gives  almost  equally  good  results. 

The  upper  limits  of  the  stomach  are  apt  to  be  obscured  by 
liver  and  lung  ;  the  lower  border  should  be  a  curve  the 
lowest  point  of  which  does  not  reach  the  transverse  umbihcal 
plane.  By  means  of  auscultatory  percussion  displacements 
of  the  stomach  as  well  as  dilatation  may  be  recognised. 
Doubtful  tumours  may  be  suspected  to  be  of  the  stomach 
wall  if  the  gastric  note  runs  right  up  the  mass  with  no 
preliminary  change. 

Inflation  of  the  stomach  will  often  render  a  tumour 
of  the  fundus  more  apparent  than  before,  or  even  bring 
into  notice  one  that  was  hitherto  unsuspected. 

(c)  Certain  Investigations  in  the  Diagnosis  of  Gastric 
Disease,  (i.)  The  Gastric  Secretions  and  the  con- 
sideration OF  Vomited  Matter.  The  flow  of  gastric 
secretion  is  immediately  determined  by  the  presence  of 
food  in  the  stomach,  but  it  can  also  be  excited  by  the 
smell  and  probably  also  by  the  mere  sight  of  food. 

The  secretion  of  hydrochloric  acid  is  abundant  during  the 
half  hour  directly  following  the  ingestion  of  food  ;  this  acid 
at  once  enters  into  combination  with  the  albuminous 
constituents  of  the  food  and  prepares  the  way  for  the 
eventual  production  of  peptones. 

Thus  for  half  an  hour  or  perhaps  rather  longer  after  a  meal 
there  is  no  free  hydrochloric  acid  in  the  stomach  and  the 
fermentation  of  the  carbohydrate  portion  of  the  meal  pro- 
ceeds unchecked.  When,  however,  the  acid  affinities  of  the 
proteid  bases  are  satisfied  (forty-five  minutes),  the  con- 
tinued secretion  of  HCl  causes  inhibition  of  fermentation 
and  the  appearance  of  free  acid.  A  largo  amount  of  proteid 
in  a  meal  delays  the  appearance  of  free  acid,  and  much 
carbohydrate  has  the  opposite  effect. 

Lactic  acid  is  never  present  at  the  same  time  as/;"ee  hydro- 
chloric acid  ;  indeed,  except  for  such  as  may  be  taken  in 
with  the  food,  lactic  acid  is  not  found  in  the  lu^ilthy 
stomach. 

Pepsin  is  always  present  where  there  is  any  free  HCl,  and 
very  often  when  there  is  not  ;  the  secretion  of  this  ferment 
is  much  less  easily  inhibited  than  is  that  of  the  acid. 


326  MEDICAL  DIAGNOSIS 

Vomiting  may  be  due  to  a  great  many  different  causes 
such  as  : — 

(a)  Local  inflammation  of  the  stomach,  whether  acute 
or  chronic  ;  dilatation  of  the  stomach,  whether  obstruc- 
tive or  atonic. 

(6)  Reflex  causes,  such  as  obstruction  of  the  intestine, 
peritonitis,  bihary  or  renal  colic. 

(c)  Emotional  causes,  such  as  fright,  rage,  or  disgust. 
{d)  Toxic    causes.      Certain   drugs,    such    as    alcohol, 
tobacco,  opium   or  chloroform,  and    morbid   blood  con- 
ditions, such  as  uraemia,  the  vomiting  of  pregnancy  or  the 
periodic  vomiting  which  is  probably  due  to  "  acidosis." 

(e)  Diseases   of  the   Central  Nervous  System,   such   as 
cerebral  tumour,  meningitis,  concussion,  locomotor  ataxy, 
and  migraine. 
The  vomit  is  acid  unless   (1)  it  is  mixed  with  intestinal 
contents  ;   (2)  it  comes  from  an  oesophageal  pouch  ;   (3)  in 
a  very  few  cases  of  (a)  cancer  of  the  stomach,  (6)  achyha. 
In  cases  of  gastric  carcinoma  the  acidity  is  due  to  bound 
acid,  which  is  but  rarely  completely  absent,  though  com- 
monly there  is  no  free  acid  to  be  found. 

The  type  of  vomiting  may  assist  the  diagnosis.  Thus 
cerebral  vomiting  is  free  from  effort,  not  preceded  by  nausea, 
and  independent  of  food. 

In  dilatation  of  the  stomach  the  vomit  is  often  copious  and 
offensive  from  the  presence  of  fatty  acids  ;  it  is  brought  up 
at  longish  intervals  of,  say,  twenty-four  to  thirty-six  hours 
and  contains  food  which  was  swallowed  many  hours 
previously. 

Vomiting  at  a  more  or  less  constant  hour  each  day  is  seen  in 
pregnancy,  and  the  morning  vomit  of  the  chronic  alcoholic 
is  well  known. 

In  gastric  ulcer  the  vomiting  often  occurs  twenty  to  thirty 
minutes  after  the  food  is  swallowed  and  is  preceded  by  pain, 
which  is  relieved  when  the  stomach  is  emptied  ;  the  material 
vomited  is  likely  to  show  advanced  proteid  digestion  for  the 
time  it  has  been  in  the  stomach. 

In  chronic  gastritis  and  in  simple  hypo-acidity  the  vomit 
may  contain  much  mucus  and  poorly-digested  or  even 
decomposing  proteid.     Of  course  all  stomachs  secrete  a  good 


DISEASES   OF   THE   ALIMENTARY   TRACT      327 

deal  of  mucus,  but  this  is  largely  digested  in  a  medium  so 
acid  as  the  healthy  gastric  juice. 

Fsecal  vomiting  indicates  intestinal  obstruction  (usually 
complete  obstruction),  and  the  further  the  obstruction  from 
the  pylorus  the  greater  the  scope  for  true  fsecal  vomiting. 

Blood  which  has  been  partly  digested  in  the  stomach  before 
being  vomited  assumes  the  characteristic  coffee-ground 
appearance. 

The  examination  of  vomited  matter  chemically  and  micro- 
scopically does  not  provide  very  trustworthy  information  ; 
for  these  purposes  a  test  meal  should  be  employed. 

(ii.)  Test  Meals  and  their  Analysis.  Since  the  gastric 
secretions  are  profoundly  modified  by  diseases  of  the  stomach 
and  elsewhere  much  information  can  be  gained  by  with- 
drawing the  stomach  contents  and  analysing  them  at  certain 
intervals  after  a  meal  of  known  composition  has  been 
eaten. 

A  variety  of  test  meals  have  from  time  to  time  been 
advocated  and  used  by  different  observers  ;  but  the  precise 
composition  of  the  meal  does  not  very  much  matter  provided 
that  the  following  points  are  remembered  : — First,  do  not 
introduce  into  the  stomach  any  appreciable  amount  of  any 
of  the  substances  for  which  you  are  afterwards  going  to  test 
the  gastric  content.s — for  example,  do  not  give  a  pint  of  milk 
if  you  are  anxious  as  to  the  subsequent  presence  of  lactic 
acid.  Secondly,  arrange  your  meal  with  great  care  so  as  to 
approximate  to  a  certain  extent  in  quality,  quantity,  and 
time  of  administration  to  the  ordinary  physiological  pro- 
cesses and  habits  of  the  particular  individual.  Thus,  if  a 
man  habitually  never  takes  any  breakfast  do  not  give  him 
a  test  meal  of  egg,  bread  and  butter,  and  tea  at  8.30  in  the 
morning,  for  by  so  doing  you  will  call  on  his  stomach  for 
certain  activities  quite  foreign  to  its  own  particular  ])hysio- 
logical  expressions,  and  the  results  may  well  be  most  mis- 
leading. Thirdly,  remove  the  meal  at  the  time  wlien  the 
maximum  activity  of  gastric  secretion  is  in  progress  ;  this 
varies  greatly  with  the  individual  and  depends  on  the 
motility  of  the  stomach  to  some  extent.  Hence,  several  test 
meals  may  be  necessary  to  determine  the  optimum  time  of 
removal  for  the  particular  patient. 


328  MEDICAL   DIAGNOSIS 

Several  standard  test  meals  are  described,  but  we  think 
that  the  poor  results,  from  a  diagnostic  point  of  view,  which 
are  so  often  experienced  are  largely  due  to  too  slavishly 
adhering  to  one  particular  meal  regardless  of  the  habits  of 
the  patient. 

Ewald's  test  breakfast  is  the  meal  most  commonly 
employed  in  this  country.  It  consists  of  40  grms.  of  white 
bread  and  400  cc.  of  water  or  weak  tea  without  millc  or  sugar. 
This  meal  should  be  removed  about  one  hour  after  adminis- 
tration. Only  from  40  to  80  cc.  should  be  recoverable  ;  any 
considerable  excess  indicates  hypersecretion  or  motor 
insufficiency. 

Riegel's  test  meal  consists  of  200  grms.  of  lean  beef, 
150  grms.  of  mashed  potatoes,  and  a  plate  of  bouillon.  This 
meal  ofiEers  a  much  stronger  stimulus  to  the  secretory 
mechanism  of  the  stomach  than  Ewald's.  It  should  not  be 
removed  for  three  or  four  hours. 

Fischer's  test  meal  is  a  combination  of  both  of  the  above 
and  is  probably  as  good  as  any.  It  consists  of  40  grms.  of 
white  bread,  200  grms.  of  lean  beef,  and  400  cc.  of  water.  It 
should  be  removed  in  three  hours. 

It  is  a  good  plan  to  estimate  the  motihty  of  the  stomach 
by  watching  the  passage  of  bismuth  out  of  the  organ  with  a 
fluoroscopic  screen  instead  of  settling  arbitrarily  the  time 
when  a  given  test  meal  shall  be  withdrawn  ;  the  optimum 
time  for  removal  can  be  gauged  in  this  manner.  Better 
results  are  obtained  if  the  stomach  tube  is  passed  once  or 
twice  previously  in  order  to  accustom  the  patient  to  its  use. 
Lastly,  in  cases  in  which  there  is  a  strong  nervous  element 
and  the  symptoms  are  definitely  periodic,  it  is  well  to 
administer  the  test  meal  at  such  a  time  that  it  can  be  with- 
drawn when  the  usual  symptoms  are  at  their  height. 

To  withdi'aw  the  meal  the  soft  stomach  tube  is  passed 
exactly  as  described  for  the  oesophageal  bougie  (p.  322)  ; 
the  patient  is  then  instructed  to  lean  forward,  to  keep  on 
breathing  through  his  nose,  and  to  contract  forcibly  his 
abdominal  muscles  ;  this  is  usually  sufficient  to  return  the 
gastric  contents.  If  not,  millc  the  tube  gently  with  the 
fingers,  withdraw  it  a  httle,  and  push  it  down  into  the 
stomach  again.     It  is  not  advisable  to  pour  water  down  the 


DISEASES    OF   THE   ALBIEXTARY   TRACT      329 

tube  for  the  purpose  of  '"  siphoning  '"  off  the  contents,  as 
this  alters  the  acid  values. 

The  following  examinations  can  now  be  made  : — 

(1)  Total  Volume  of  Material  Removed.  In  the  case  of 
Ewald's  test  breakfast  only  one-sixth  of  the  original 
400  cc.  should  be  regained*(say  50  to  70  cc). 

If  the  stomach  was  washed  out  (as  it  should  be)  and  left 
empty  the  night  before,  100  cc.  at  the  very  outside  should 
be  allowed  for  healthy  gastric  secretion  throughout  the 
night,  so  that  the  removal  of  more  than  170  cc.  of  material 
after  the  test  breakfast  indicates  hypersecretion  or  motor 
insufficiency  ;  on  the  other  hand,  in  the  majority  of  healthy 
stomachs  there  is  practically  no  secretion  so  long  as  food 
is  neither  swallowed  nor  smelled,  so  that  the  removal  of 
so  little  as  40  to  70  cc.  must  not  be  regarded  as  evidence 
of  hyposecretion.  , 

(2)  The  Presence  of  Free  Hydrochloric  Acid. 

(a)  If  a  Congo-red  test  paper  is  dipped  into  the 
material  a  bright-blue  colour  is  produced  by  free 
mineral  acid.  Free  lactic  acid  also  turns  this  paper 
blue,  but  the  colour  is  much  less  pronounced. 

(6)  Gunzberg's  test  is  the  one  usually  adopted.  The 
solution  is  vaniHin  1  part,  phloroglucin  2  parts,  and 
alcohol  30  parts  ;  it  should  be  kept  in  the  dark  and 
tightly  corked.  A  few  drops  of  this  solution  are  eva- 
porated slowly  just  to  dryness  in  a  porcelain  capsule  ; 
a  drop  of  the  gastric  content  is  now  run  up  to  the  edge 
of  the  deposit  and  further  gentle  heat  applied.  At  the 
point  of  contact  a  crimson  line  is  formed  if  free  mineral 
acid  is  present  to  the  extent  of   005  per  cent. 

Absence  of  free  HCl  at  the  times  when  it  should  be 
present  may  occur  in  malignant  disea.se,  achylia,  or  in 
true  chronic  gastritis  ;  it  should  be  present  forty  minutes 
after  a  carbohydrate  meal  or  seventy-five  minutes  after 
a  proteid  meal. 

(3)  The  Total  Acidity.  To  estimate  this  the  gastric 
contents  should  be  filtered,  preferably  by  a  .suction  filter  : 
10  cc.  of  the  filtrate  are  titrated  with  decinormal  caustic 
soda,  the  indicator  being  a  few  drops  of  ^  per  cent. 
phcnolphthalein  in  alcohol.     The  number  of  cc.  of  caustic 


330  MEDICAL   DIAGNOSIS 

solution  necessary  to  turn  the  indicator  is  multiplied  by  10, 
and  the  result  is  the  total  acidity  per  cent.  For  example, 
if  5  cc.  of  caustic  are  used  to  neutralise  the  10  cc.  of  gastric 
juice  the  total  acidity  is  expressed  as  50  acidity  per  cent. 

In  health  the  total  acidity  per  cent,  varies  from  40  to  60 
one  hour  after  the  test  breakfast  and  from  100  to  120 
three  hours  after  the  Riegel  test  meal. 

If  desired  the  total  acidity  can  be  expressed  gravi- 
metrically  as  the  percentage  acidity  of  HCl  in  the  gastric 
juice.  Clinically  it  is  sufficient  to  remember  that  an 
acidity  per  cent,  of  55  is  equivalent  to  the  average  healthy 
gastric  acidity  of  '2  per  cent. 

(4)  To  Estimate  the  Free  HCl,  titration  with  decinormal 
soda  is  carried  out  until  the  test  for  free  acid  is  negative, 
for  it  is  assumed  that  the  free  acid  is  neutralised  by  the 
soda  solution  before  the  bound  acid.  Accordingly  during 
the  titration  repeated  investigations  are  made  with 
Gunzberg's  reagent  and  a  drop  of  the  gastric  juice,  which 
is  removed  on  a  glass  rod  after  stirring  in  the  freshly  added 
soda. 

This  process  is  rather  tedious,  but  is  reasonably  accurate. 

(5)  Lactic  Acid.  This  acid  is  tested  for  with  Uffel- 
mann's  reagent.  This  consists  of  2  per  cent,  carbolic 
acid,  to  20  cc.  of  which  one  drop  of  10  per  cent,  ferric 
chloride  is  added  just  before  use. 

The  amethyst  colour  of  this  solution  becomes  canary- 
yellow  in  the  presence  of  lactic  acid. 

Mineral  acids  destroy  the  purple  tint  of  the  reagent, 
leaving  a  perfectly  colourless  solution. 

(6)  Pepsi7i.  This  is  almost  always  present  if  there  is 
any  free  hydrochloric  acid,  so  that  practically  it  need  only 
be  investigated  in  cases  in  which  there  is  no  free  acid, 
and  even  in  these  it  is  nearly  always  found. 

To  examine  for  it,  it  is  necessary  to  add  sufficient  HCl 
to  the  gastric  contents  till  there  is  free  acid  present,  as 
shown  by  the  Congo-red  test  paper.  A  disc  of  boiled 
white  of  egg  is  now  put  into  the  solution  and  the  whole 
placed  in  an  incubator  at  37°  C.  If  pepsin  is  present  the 
edges  of  the  disc  of  egg  white  will  become  rounded  by 
the  ferment  action  in  from  half  an  hour  to  three  hours. 


DISEASES   OF   THE   ALIMENTARY   TRACT      331 

(7)  Microscopical  Examination.  A  wet  preparation 
should  be  used,  that  is  to  say,  a  few  drops  of  the  gastric 
contents  on  which  a  cover-slip  is  floated.  One  drop  of 
dilute  watery  methylene  blue  may  conveniently  be  mixed 
in  with  the  solution.  Excess  of  moisture  should  be 
removed  by  blotting-paper  and  the  cover-slip  ringed  with 
vaseline  or,  better,  paraffin  wax  for  examination  with  an 
oil  immersion  lens. 

The  following  points  may  be  elicited. 

(a)  Boas-Oppler  Bacillus.  This  bacillus  is  said  only 
to  be  present  in  cases  of  malignant  gastric  tumours,  or 
possibly  in  cases  of  true  chronic  gastritis,  that  is  to  say, 
where  there  is  no  free  HCl. 

It  is  a  large  bacillus,  often  growing  into  long  threads 
or  chains  like  the  anthrax  bacillus,  it  is  Gram-positive, 
does  not  form  spores,  and  is  easily  cultivated  on^nedia 
which  have  been  acidified  with  lactic  acid. 

{b)  Sarcince,  groups  of  cocci  (Gram-positive)  occur- 
ring in  groups  of  eight,  formed  by  division  into  three 
planes  at  right  angles  to  each  other. 

Sarcin.Te  are  very  characteristic  of  dilated  stomach, 
but  are  seldom  seen  in  cases  of  malignant  disease. 

(c)  Moulds,  Yeasts,  and  other  Varieties  of  Bacteria. 
Moulds  and  yeasts  are  present  where  there  is  free  HCl. 

Bacteria  only  occur  in  large  numbers  when  there  is 
no  free  acid. 

(f/)  Pus  Cells  are  but  rarely  present ;  they  may  occur 
where  there  is  an  ulcerating  new  growth  or  in  cases  of 
phlegmonous  gastritis. 

(e)  Very  occasionally  fragments  of  carcinoma  or 
sarcoma  may  be  visible. 

(8)  The  Presence  of  Blood.  The  presence  of  blood  may 
of  course  be  obvious,  or  the  amount  nuiy  bo  so  small  that 
it  can  only  bo  demonstrated  by  the  occult  blood  tost. 

The  Occult  Blood  Test.  The  best  test  for  very  minute 
traces  of  blood  is  that  described  by  Colwell  and  MacCor- 
mack  : — 

To  prepare  the  reagent  : 

Dissolve  •!  grm.  benzidene  and  1  grm.  of  sodium 
perborate  in  10  cc.  of  glacial  acetic  acid. 


332  MEDICAL  DIAGNOSIS 

This  solution  should  be  freshly  made  for  each  days 
work. 

To  prepare  an  etheral  extract  of  the  suspected  material : 

Take  5  cc.  of  the  material  to  be  tested  (vomit,  fseces  or 
urine)  and  shake  for  two  minutes  with  5  cc.  of  glacial 
acetic  acid  in  a  stoppered  vessel.  Add  to  this  10  cc.  of 
ether  and  shake  again.  Now  add  2  or  3  cc.  of  water  and 
allow  the  etheral  extract  to  rise  to  the  top  of  the  fluid  by 
standing  the  vessel  for  a  few  minutes. 

To  perform  the  test  : 

Place  5  cc.  of  the  etheral  extract  in  an  evaporating  dish 
and  allow  the  ether  to  evaporate.  Add  1  cc.  of  the  benzi- 
dene  perborate  solution.  If  blood  is  present  an  intense 
blue  colour  appears.  If  the  colour  comes  up  slowly  or 
is  greenish  rather  than  blue  the  blood  is  present  in  the 
most  minute  traces. 

A  positive  test  is  given  by  any  form  of  fresh  animal 
food,  even  fish,  and  also  green  vegetable  matter,  so  that 
the  patient  must  be  fed  for  forty-eight  or  seventy-two 
hours  on  milk,  eggs,  tea,  bread  and  butter,  and  potatoes 
before  the  test  can  be  profitably  applied. 

Iodides,  which  give  a  positive  reaction  when  peroxide 
of  hydrogen  is  used,  are  negative  to  perborate. 

The  test  can  of  course  be  applied  directly  to  the  sus- 
pected material,  but  the  use  of  an  etheral  extract  gives 
very  much  more  reliable  information.* 

COXCLUSIONS   TO   BE   DEAWN   FROM  THE  EXAMINATION  OF 

Test  Meals.  It  is  obvious  that  the  most  important  facts 
to  be  ascertained  from  test  meals  are  first  the  presence  or 
absence  of  free  HCl,  and  secondly  the  proportion  of  free  and 
combined  acid  in  regard  to  the  total  acidity.  The  results 
of  the  remaining  investigations  vary  almost  directly  with 
the  amount  of  free  acid  present  and  therefore  are  mainly 
confirmatory  in  their  scope.  (Some  observers  place  more 
reliance  on  the  presence  of  lactic  acid  than  on  the  absence 
of  free  HCl  in  the  diagnosis  of  malignant  disease.) 

In  the  consideration  of  gastric  disease  cases  can  be  sharply 

*  In  the  case  of  solid  fseces  an  etheral  extract  is  best  made  by  rubbing  up 
a  small  piece  of  fspcal  matter  with  glacial  acetic  acid  in  a  watch-glass,  diluting 
with  water,  and  then  adding  the  ether  as  above  described. 


DISEASES   OF   THE   ALIMENTARY   TRACT      333 

divided  into  two  classes — the  Innocent  and  the  Malignant : 
it  is  always  of  prime  importance  to  exclude  the  latter. 

The  justifiable  deductions  to  be  drawn  from  the  acidity 
of  the  stomach  contents,  based  on  the  summary  by  Sahli, 
are  as  follows  : — 

(a)   With  Normal  Acid  Secretion  there  may  be  : 

(1)  Some  cases  of  ulcer  of  the  stomach  (more  often 
chronic  than  acute). 

(2)  Gastric  Neuroses. 

(3)  Simple  atony. 

(6)   With    Increased    Free    HCl    (that    is,    more    than 
•25  per  cent,  and  total  acidity  per  cent,  of  more  than  70)  : 

(1)  Most  cases  of  simple  ulcer,  either  gastric  or 
duodenal. 

(2)  Hypersecretion,  either  continuous  or  only  during 
digestion,  but  not  the  increased  secretion  (appaient) 
of  impaired  motility. 

(3)  Gastroxynsis,  or  the  paroxysmal  hypersecretion 
which  occurs  in  some  forms  of  neurosis  and  is  accom- 
panied by  copious  acid  vomit. 

(4)  Some  cases'  of  chlorosis. 

(5)  The  initial  stages  of  chronic  gastric  catarrh, 
(c)   With  Diminished  Acidity  : 

(1)  Most  febrile  conditions. 

(2)  Severe  anaemias. 

(3)  The  later  stages  of  chronic  gastric  catarrh. 

(4)  Any  state  of  profound  debility. 

(5)  The  later  stages  of  heart  disease. 

{d)   With  the  Repeated  Absence  of  Free  HCl  : 

(1)  More  advanced  stages  of  group  (c). 

(2)  The  acute  specific  infective  diseases. 

(3)  Malignant  disease  of  the  stomach. 

(4)  The  late  stages  of  malignant  disease  elsewhere. 

(5)  Pernicious  anaemia. 

The  complete  absence  of  free  HCl,  as  shown  by  several 
examinations,  is  always  of  significance  ;  for  the  rest  it  is 
important  to  remomber  that  average  acidities  vary  within 
considerable  limits  with  the  nationality  and  al.so  with  the 
individual. 

(iii.)  The  Motility  of  the  Stomach.     Undoubtedly  the 


334  MEDICAL   DIAGNOSIS 

best  method  of  investigating  the  motihty  of  the  stomach  is 
to  make  the  patient  swallow  6  oz.  of  semi-solid  bismuth  paste 
and  to  watch  with  a  fluoroscopic  screen  the  movement  of  the 
stomach  and  the  passage  of  its  contents  into  the  duodenum. 

If  the  use  of  the  X-rays  is  not  practicable  a  meal  consisting 
of  meat,  bread,  and  tea  may  be  given  without  lavage  at 
7  o'clock  in  the  evening. 

The  stomach  contents  should  then  be  removed  (before 
any  further  food  has  been  taken)  at  7  o'clock  in  the  morning. 
The  presence  of  food  in  the  material  removed  denotes  great 
impairment  of  motility. 

It  is  probable  that  there  is  impaired  motility  if  a  fasting 
stomach  contains  more  than  100  cc.  of  secretion  first  thing 
in  the  morning. 

After  an  ordinary  "  mixed  "  meal  the  healthy  stomach  is 
empty  within  seven  hours. 

Excessive  motility  for  the  most  part  accompanies  hyper- 
acidity ;  it  is  therefore  common  in  cases  of  gastric  ulcer, 
duodenal  ulcer,  and  gastric  neurosis. 

Impaired  motility  is  more  serious,  and  practically  always 
indicates  more  or  less  dilatation  of  the  stomach  ;  this  maybe 
due  to  simple  atony  of  the  musculature  or  to  some  obstruc- 
tion to  the  outflow  through  the  pylorus.  In  the  latter  case 
there  may  be  definite  muscle  hypertrophy  combined  with 
the  dilatation,  the  result  of  an  attempt  to  overcome  the 
obstruction. 

(iv.)  The  Absorptive  Power  of  the  Stomach.  This 
function  is  not  commonly  of  great  importance,  since  healthy 
intestines  can  easily  compensate  for  the  absence  of  normal 
gastric  absorption,  especially  if  the  motility  of  the  stomach 
is  unimpaired.  Further,  the  absorption  from  the  stomach  is 
diminished  in  practically  every  gastric  disorder  and  abolished 
temporarily  in  acute  infections. 

If  it  is  desired  to  test  the  absorptive  power  of  the  stomach 
a  gelatine  capsule  containing  3  gr.  of  potassium  iodide 
should  be  administered  (preferably  with  an  Ewald's  test 
breakfast  in  order  to  ensure  constant  conditions  (Sahli)  ). 
Iodine  should  appear  in  the  saliva  in  from  five  to  fifteen 
minutes.  It  should  also  be  present  in  the  urine  within 
half  an  hour.     The  test  is  made  by  adding  to  some  saliva 


DISEASES  OF  THE  ALBIENTARY  TRACT      335 

(or  urine)  a  little  starch  and  a  drop  or  two  of  strong  HCl  ; 
iodine  is  shown  by  a  blue  coloration.  This  test  may  be 
tried  with  the  saliva  every  few  minutes  until  it  is  positive. 
The  practical  value  of  this  test  is  verj^  small. 

{d)  Clinical  Varieties  of  Gastric  Disorders.  The  sympto- 
matology of  the  various  gastric  disturbances  is  so  anomalous 
and  the  physical  signs  are  often  so  vague  that  accurate 
diagnosis  becomes  a  matter  of  the  utmost  difficulty.  It  is 
especially  important  always  to  remember  that  gastric 
symptoms  are  present  in  very  many  diseases  which  in 
themselves  are  quite  distinct  from  any  primary  stomach 
affection.  In  such  cases  it  may  be  fatal  to  focus  the  atten- 
tion on  the  gastric  organ  or  even  on  the  alimentarj^  tract 
at  all.  It  is  important  to  cultivate  a  comprehensive  outlook 
in  all  cases  of  disease,  but  especially  so  in  cases  in  which  the 
chief  s5^mptoms  are  referred  to  the  stomach.  To  illui^trate 
this  truth  it  is  only  necessary  to  mention  the  dyspeptic 
symptoms  of  early  pulmonary  tuberculosis  and  old-standing 
valvular  disease  of  the  heart,  the  gastric  crises  of  tabes 
dorsalis,  the  vomiting  of  uraemia,  and  the  sickness  and 
abdominal  pain  of  Addison's  disease.  In  any  of  these  a 
diagnosis  of  gastritis  would  be  nothing  more  than  a  confes- 
sion of  ignorance,  and  treatment  based  on  such  a  diagnosis 
must  prove  far  from  satisfactory. 

Disorders  of  the  stomach  may  be  considered  under  cer- 
tain definite  headings,  but  it  must  be  understood  that  any 
sharp  classification  is  impossible  in  view  of  the  inevitable 
overlapping  that  must  occur  from  the  association  of  two  or 
more  of  the  under-mentioned  conditions  : — 

Simple  Acute  Gastritis. 
Phlegmonous  Gastritis. 
A.  Inflammation     . .  . .  ■{  Toxic  Gastritis. 


Chronic  Gastritis. 
Atrophic  Gastritis. 


B.  Gastric  Ulcer. 

[  Simple  or 
atonic. 


C.   Gastrectasis 

Obstructive 


Simple. 
Malignant. 
Congenital     Pyloric 
Obstruction. 


336  MEDICAL  DIAGNOSIS 

D.  New  Growth. 


E.  Disorders  of  Secretion 


Achylia. 

Hypersecretion. 
Hyper-acidity. 
Hypo-acidity. 
f  Anorexia  Nervosa. 
F.  Essential  Neuroses        . .  j  Bulimia. 

I  Pica. 

A.  Inflammation,  (i.)  Acute  Gastritis.  This  condition  is 
produced  by  the  ingestion  of  irritating  or  toxic  material — 
for  example,  excess  of  alcohol  (in  those  who  are  unused  to  it), 
unsuitable  or  highly-spiced  foods  or  those  that  are  tainted, 
and  sometimes,  in  susceptible  persons,  by  simple  chill. 

A  second  group  of  cases  are  found  in  the  later  stages  of 
many  chronic  diseases,  such  as  tuberculosis,  exophthalmic 
goitre,  pernicious  anaemia,  etc. 

Lastly,  an  apparent  acute  gastritis  may  be  the  first 
symptom  of  an  acute  infection,  such  as  pneumonia  or  scarlet 
fever,  especially  when  the  patient  is  a  child. 

The  symptoms  are  loss  of  appetite,  vomiting,  headache, 
and  usually  more  or  less  epigastric  pain.  There  is  a  furred 
tongue  and  generally  constipation,  though  sometimes  there 
is  an  associated  enteritis  with  diarrhoea. 

The  mucous  membrane  of  the  stomach  is  inflamed  and 
coated  with  mucus,  the  vomit  contains  undigested  and  often 
fermenting  food,  as  well  as  slimy  mucus  ;  it  is  practically 
always  deficient  in  acidity  and  free  HCl  may  well  be  entirely 
absent.  When  the  retching  is  persistent  the  vomit  may 
contain  bile. 

The  diagnosis  does  not  commonly  present  much  difficulty. 
Gastric  crisis  may  be  excluded  by  examining  for  the  other 
signs  of  Tabes  {vide  p.  544). 

The  acute  exanthems  in  children  may  always  be  suspected 
and  their  appropriate  features  sought  for. 

In  the  majority  of  cases  the  history  of  the  recently-taken 
food  and  drink  affords  a  valuable  clue. 

The  promptness  with  which  primary  acute  gastritis 
yields  to  starvation  and  a  mercurial  purge  is  worthy  of 
note. 

(ii.)  Acute    Phlegmonous    Gastritis.     This    condition    is, 


DISEASES   OF   THE   ALIMENTARY   TRACT      337 

happily,  rare  ;  it  is  an  acute  streptococcal  inflammation  of 
all  the  coats  of  the  stomach.  It  may,  but  usually  does 
not,  go  on  to  abscess  formation.      The  etiology  is  obscure. 

The  symptoms  are  very  acute  epigastric  pain,  nearly 
always  accompanied  by  voimting.  The  vomited  matter  is 
usually  totally  anacid,  and  even  the  ferments  may  be 
absent.  There  is  always  evidence  of  profound  constitu- 
tional disturbance  and  of  septic  absorption.  The  condition 
is  rapidly  fatal  except  in  a  few  cases.  In  these  the  inflam- 
mation localises  with  the  formation  of  an  abscess  which 
ruptures  into  the  stomach  (a  rare  event). 

(iii.)  Toxic  Gastritis.  By  this  is  meant  an  acute  gastritis, 
depending  on  the  swallowing  of  some  definitely  poisonous 
material,  such  as  oxalic  or  mineral  acid,  caustic,  hniment, 
arsenic,  or  the  hke. 

The  symptoms  are  those  a  of  a  very  acute  gastritis /asso- 
ciated with  profound  collapse,  which  often  proceeds  to 
coma. 

The  diagnosis  depends  on  the  history  of  swallowing  some 
poison  and  of  the  onset  of  symptoms  with  appalhng  sudden- 
ness, the  possible  evidence  of  burns  about  the  mouth  or 
pharynx,  the  presence  of  blood  and  shreds  of  mucus  in  the 
vomited  material,  the  smell  of  this  and  its  analysis  for  such 
poisons   as  may  be  suspected. 

(iv.)  Chronic  Gastritis.  Essentially  this  is  a  chronic  catar- 
rhal affection  of  the  gastric  mucous  membranes,  associated 
with  the  production  of  excessive  mucus  and  a  deficiency  in 
free  HCl.  A  common  cause  is  the  prolonged  ingestion  of 
irritating  and  unsuitable  articles  of  diet,  particularly  alcohol ; 
again,  a  diet  that  is  in  itself  harmless  may  be  rendered 
irritating  by  imperfect  mastication.  Another  cause  is 
chronic  venous  engorgement ;  this  variety  is  a  conspicuous 
feature  of  advanced  valvular  disease  of  the  heart  and  also 
of  portal  cirrhosis. 

Chronic  gastritis  is  often  secondary  to  local  carcinoma  and 
is  met  with  in  the  later  stages  of  any  chronic  debilitating 
disease. 

The  symptoms  are  very  variable,  and  include  : — 

(a)  Slight  general  malaise  with  a  tendency  to  headache. 
(6)  Epigastric    pain    with    slight    diffuse    tenderness, 

M.D.  22 


338  MEDICAL  DIAGNOSIS 

most  apparent  from  one  and  a  half  to  three  hours  after  a 
meal.  The  pain  is  sometimes  described  as  going  through 
the  chest  to  the  interscapular  region,  mostly  on  the  left 
side, 

(c)  Vomiting  and  nausea  ;  frequently  immediately  on 
rising  in  the  morning,  sometimes  two  to  three  hours  after 
a  meal. 

(d)  Constipation  is  the  rule,  but  by  no  means  invariable  ; 
indeed,  alcoholics  are  often  prone  to  diarrhoea. 

(e)  The  tongue  is  furred  and  flabby,  and  there  is  often 
an  unpleasant  taste  in  the  mouth. 

(/)  Flatulent   distension   and   gaseous   eructations   are 

common. 

The  vomited  material  or  the  wash-out  from  a  test  meal 
shows  excess  of  mucus,  diminution  or  absence  of  free 
HCl,  undigested  and  often  fermented  food  and  the  presence 
of  organic  acids. 

The  total  acidity  is  diminished  as  a  rule,  as  is  the  total 
secretion. 

The  morning  vomit  of  the  alcoholic  consists  entirely  of 
bile-stained  mucus. 

The  symptoms  depend  to  a  certain  extent  on  the  motility 
of  the  stomach.  When  this  is  normal  or  increased,  the 
symptoms  are  slight,  because  the  food  is  passed  on  rapidly 
to  the  intestine,  where  compensatory  digestion  takes  place. 
When  the  motility  is  diminished,  the  symptoms  are  aggra- 
vated.     As  a  rule  the  motility  is  somewhat  diminished. 

The  differential  diagnosis  may  be  far  from  simple.  The 
history  is  important,  and  primary  diseases  must  be  excluded. 
When  this  has  been  done  the  chief  trouble  is  to  exclude 
gastric  ulcer,  malignant  disease  of  the  stomach,  and  atonic 
gastrectasis. 

In  Gastric  Ulcer  the  pain  is  more  severe  and  occurs  sooner 
after  food,  the  tenderness  is  more  acute  and  often  localised, 
while  a  test  meal  shows  hyperacidity  and  absence  of 
mucus. 

Definite  hsematemesis  (not  capillary  oozing)  is  of  the 
utmost  importance  as  indicating  ulcer  provided  cirrhosis 
of  the  Hver  and  carcinoma  can  be  excluded. 

In  Gastric  Carcinoina  the  pain  is  more  severe  and  more 


DISEASES   OF   THE   ALIMENTARY   TRACT      389 

constant  ;  vomiting  is  more  frequent.  A  mass  may  be 
felt  and  cachectic  symptoms  are  not  long  delayed.  Further, 
obstructive  symptoms  may  be  present,  and  the  Boas- 
Oppler  bacillus  may  be  found  in  the  stomach  contents  as 
well  as  lactic  acid,  but  no  free  HCl. 

In  Atonic  Gastrectasis  the  dilated  stomach  can  be  diagnosed 
by  auscultatory  percussion,  X-rays,  and  the  test  meal,  which, 
with  the  absence  of  visible  peristalsis  or  a  palpable  tumour, 
will  help  to  exclude  organic  obstruction. 

(v.)  Atrophic  Gastritis.  This  consists  in  atrophy  of  the 
gastric  mucous  membrane  and  is  most  frequently  seen  as  the 
result  of  long  continued  chronic  gastric  catarrh  ;  it  also 
occurs  as  the  result  of  infiltrating  gastric  carcinoma,  and 
sometimes  when  the  malignant  growth  is  quite  localised. 

Achylia  is  a  necessary  accompaniment  to  atrophic 
gastritis,  but  is  sometimes  found  as  a  pure  neurosis.    ^ 

The  chief  symptom  is  repeated  vomiting  soon  after  meals  ; 
in  cases  in  which  the  motility  is  good  there  may  be  no  symp- 
toms. A  test  meal  will  surely  demonstrate  achylia,  and  so 
will  help  in  the  diagnosis  of  atrophic  gastritis.  The  food 
is  returned  practically  unchanged,  there  is  no  free  acid,  the 
total  acidity  per  cent,  is  under  5,  there  is  no  organic  acid, 
and  pepsin  is  absent. 

These  findings  do  not  necessarily  exclude  carcinoma.  But 
the  absence  of  obstruction  as  shown  by  X-rays  would  suggest 
the  presence  of  simple  atrophy  rather  than  growth. 

It  should  be  remembered  that  the  atrophy  of  the  gastric 
mucosa  is  secondary  to  some  other  condition  in  the  great 
majority  of  cases  and  is  therefore  a  symptom  rather  than  a 
disease  ;  also  that  the  presence  of  achylia  in  itself  is  not 
sufficient  to  warrant  the  diagnosis  of  atrophic  gastritis, 
since  all  gastric  secretions  may  be  suspended  from  purely 
functional  nervous  causes. 

B.  Gastric  Ulcer.  Etiology.  Gastric  ulcer  is  mucli  more 
common  in  women  than  men  and  is  most  often  seen  between 
the  ages  of  20  and  35  years,  but  practically  no  age  is  immune. 
Its  causation  is  obscure,  but  tlic  fact  that  it  is  associated 
with  hyperacidity  and  very  frequently  with  ana?mia  seems 
rather  to  support  the  idea  that  minute  venous  thromboses 
in  the  gastric  submucosa  may  be  the  first  stage  and  that 

22—2 


340  MEDICAL  DIAGNOSIS 

auto -digestion  of  the  mucous  membrane  overlying  these 
"  infarcted  "  areas  is  the  second  stage.  Possibly  bacteria 
may  play  a  part  in  the  production  of  the  gastric  ulcer  ; 
certainly  oral  sepsis  and  extreme  constipation  are  very  often 
features  of  such  cases,  and  these  are  both  potential  sources 
of  bacterial  invasion  of  the  stomach. 

Situation  and  Varieties.  The  acute  ulcers  are  often 
multiple  ;  they  are  most  often  to  be  found  on  the  lesser 
curvature  of  the  stomach  and  rather  near  the  pylorus,  but 
may  well  occur  in  any  part  of  the  stomach.  They  may  all 
heal  completely,  or  one  or  more  may  persist  and  gradually 
develop  into  a  chronic  ulcer.  This  is  usually  single  and  often 
bound  by  dense  adhesions  to  neighbouring  structures, 
especially  the  pancreas. 

Any  ulcer  may  perforate,  but  the  so-called  "  acute  per- 
forating ulcer  "  is  nearly  always  situated  on  the  unsupported 
anterior  wall  of  the  stomach.  Those  ulcers  which  are  on 
the  lesser  curvature  readily  form  adhesions  to  other  viscera 
and  so  do  not  commonly  perforate  suddenly,  though  not 
infrequently  they  leak  slowly  and  form  a  subphrenic  abscess. 

The  actual  rupture  of  an  "  acute  perforating  ulcer  "  and 
of  a  chronic  ulcer  may  be  equally  sudden,  but  in  the  former 
case  the  perforation  may  be  almost  the  first  sign  of  gastric 
ulcer,  and  certainly  may  occur  within  a  few  hours  of  the  very 
first  gastric  symptom,  whereas  the  chronic  ulcer  gives 
evidence  of  its  presence  for  months  or  years  before  the 
sudden  symptoms  of  perforation  supervene. 

Malignant  disease  (carcinoma)  develops  in  a  considerable 
proportion  of  chronic  ulcers  ;  hence  the  title  "  malignant 
ulcer." 

Course.  Considering  the  difficulty  in  accurately  diag- 
nosing many  cases  of  early  gastric  ulcer  and  the  impossi- 
bility of  satisfactory  home  treatment  in  the  majority  of 
cases,  it  is  perhaps  fortunate  that  perforation  takes  place 
in  only  a  very  small  proportion  of  all  cases. 

The  tendency  is  for  rapid  improvement  to  follow  appro- 
priate treatment  in  acute  cases,  but,  owing  to  a  renewal 
of  the  same  circumstances  which  originally  caused  the  first 
ulcer,  when  the  patient  resumes  her  ordinary  life  the 
majority  of  cases  relapse,  not  once  only,  but  again  and  again. 


DISEASES   OF   THE   ALIMENTARY  TRACT      341 

Of  course,  in  the  upper  classes,  where  prolonged  treatment 
can  be  carried  out  and  a  hygienic  life  persisted  in,  complete 
cure  is  more  usual  ;  but  gastric  ulcer  is  not  common  in  the 
upper  classes — it  is  shop  hands  and  domestic  servants  that 
seem  chiefly  to  be  affected. 

Since,  then,  so  many  cases  relapse,  a  chronic  ulcer  is  often 
the  result  within  a  few  years  of  the  first  symptom,  and  though 
acute  ulcers  respond  well  to  medical  treatment,  chronic 
ones  do  not ;  indeed,  the  symptoms  frequently  return  as 
soon  as  a  diet  of  solid  food  is  permitted.  The  likelihood 
of  a  chronic  gastric  ulcer  becoming  mahgnant  has  been 
mentioned,  and  this  affords  another  cogent  reason  for 
advocating  operative  interference  (gastro-jejunostonw)  as 
soon  as  chronic  gastric  ulcer  has  been  diagnosed.  Acute  ulcers 
should  not  be  submitted  to  operation,  partly  because  the}'^ 
tend  to  heal  if  given  a  chance,  and  still  more  because' they 
are  so  often  multiple. 

Symptoms  and  Signs.  The  chief  symptoms  of  gastric 
ulcer  are  as  follows  : — 

(a)  A  burning  2>ain  in  the  epigastrium  (often  localised 
to  a  definite  area)  and  occurring  from  twenty  minutes  to 
two  hours  after  a  meal — that  is  to  say,  at  the  height  of 
acid  secretion.  The  pain  may  radiate  to  the  back  and 
left  scapula  and  often  varies  with  change  of  posture.  It 
ceases  when  the  stomach  becomes  empty  and  is  the  more 
severe  the  nearer  the  ulcer  is  to  the  pylorus. 

(6)  Nausea  accompanies  the  pain,  and  in  about  20  per 
cent,  of  aU  cases  there  is  frequent  vomiting.  When  the 
patient  vomits  the  pain  is  relieved.  In  about  25  per  cent, 
of  all  cases  there  will  be  hsematemesis  sooner  or  later. 

(c)  Tenderness.  This  depends  on  the  site  of  the  ulcer, 
but  is  usually  found  over  an  area  of  1  to  2  square  inches 
about  2  inches  above  the  umbilicus  and  rather  to  the  left 
of  the  middle  liiu'.  This  localisation  of  tenderness  is  an 
important  point. 

{d)  Cutaneous  hypercesthesia  may  be  present  over  the 
same  area  as  that  just  described. 

(e)  Hyperacidity  and  increased  motility  are  almost  con- 
stant features  of  acute  ulcers  ;  normal  acidity  is  possible 
in  chronic  ulcers. 


342  MEDICAL  DIAGNOSIS 

(/)  Anaemia  and  constipation  are  the  rule  ;   the  tongue, 
however,  is  clean  if  there  is  no  associated  gastritis. 

(g)  Hcemorrhage.     This  may  be  almost  the  first  sign 
of  ulcer  or  it  may  be  long  delayed.     It  may  be  slight  in 
amount  or  very  copious.     When  very  profuse  it  may  be 
fairly  bright  red  ;   more  often  it  is  altered  by  the  stomach 
contents    and    becomes    black    and    broken    up    (coffee- 
grounds).     Sometimes  there  is  considerable  haemorrhage 
without  vomiting  ;    under  these  circumstances  the  blood 
is  passed  per  rectum  only  (melsena). 
Differential  diagnosis  of  gastric  ulcer  : — 
From  Chronic  Gastritis  {vide  p.  338). 
From  Malignant  Disease.     The  age  of  the  patient  as  well 
as  the  length  of  the  history  and  the  absence  of  cachexia  may 
be  important  points.     If  there  be  hsematemesis  it  is  likely 
to  be  much  more  profuse  and  less  frequent  in  simple  ulcer. 
The  pain  in  ulcer  is  more  paroxysmal  and  is  absent  when 
the  stomach  is  empty.     No  mass  can  be  detected.     The 
test  meal  in  simple  ulcer  shows  increased  total  acidity  and 
ample  free  acid  ;    in  carcinoma  there  is  no  free  acid,  the 
total  acidity  is  greatly  diminished,   and  the  Boas-Oppler 
bacillus  may  be    found  in  the  stomach  contents.     Definite 
obstruction,  as  shown  by  X-rays,  is  more  common  in  malig- 
nant   disease    than    in    adhesions    from    simple   ulceration. 
From  Gastrostaxis .     By  gastrostaxis  is  meant  haemorrhage 
from  the  stomach  when  there  is  no  ulceration  or  erosion  to 
account  for  it.     This  condition  may  not  be  very  common, 
but  there  can  be  no  doubt  that  it  does  occur,  since  there 
have  been  fatal  cases  where  a  most  laborious  examination 
of   the   stomach   has   failed   to    show   any   source   for   the 
bleeding. 

Like   gastric    ulcer,    gastrostaxis   is    a   disease   of   young 

women,  and  a  positive  differential  diagnosis  between  the  two 

conditions  is  impossible.     At  the   same   time  gastrostaxis 

may  be  suspected  if  the  following  features  are  present  : — 

(a)  Absence    of    any    gastric     symptoms    before    the 

haemorrhage. 

(6)  Occurrence  of  the  haemorrhage  at  or  about  the  time 
of  the  menstrual  period. 

(c)  Very  rapid  recovery  from  the  anaemia  which  results 


DISEASES    OF   THE   ALIMENTARY   TRACT      343 

from  the  loss  of  blood.  In  gastrostaxis  cases  the  haemo- 
globin is  restored  to  normal  in  four  or  five  weeks  ;  in 
gastric  ulcer  it  often  remains  reduced  for  several  months. 

(d)  The  total  acidity  is  normal  or  diminished. 
From  Duodenal  Ulcer.     An  ulcer  situated  at  or  about  the 
pyloric  ridge  may  be,  anatomically,  either  gastric  or  duodenal, 
but,  chnically,  differentiation  is  impossible.     The  following 
points  are  characteristic  of  true  duodenal  ulcer  : — 

(a)  The  male  sex  is  more  liable  than  the  female. 

(b)  The  pain  is  not  noticed  for  from  three  to  four  hours 
after  food,  and  is  relieved  by  the  next  meal  (hunger  pain). 

(c)  The  pain  and  tenderness  extend  definitely  to  the 
right  of  the  mid-line  :  sometimes  the  pain  is  referred  to 
the  right  scapula. 

(d)  A  common  tender  spot  is  at  the  junction  of  the  lower 
and  middle  thirds  of  the  line  joining  the  umbilicus'to  the 
tip  of  the  ninth  rib. 

(e)  Melsena  is  common  in  duodenal  ulcer.  Hsemate- 
mesis  is  rare,  as  indeed  is  vomiting  or  nausea. 

C.  Gastrectasis    (Dilatation    of    the    Stomach). 

(i.)  Acute  Paralytic  Distension  of  the  Stoinach.  This  rare 
condition  appears  to  be  caused  by  extreme  overloading  of  the 
stomach  with  food  and  drink  ;  it  is  not  likely  to  occur  unless 
there  is  a  certain  amount  of  previous  atony  and  is  most 
frequently  seen  in  advanced  life.  The  result  may  be  death 
from  heart  failure,  especially  if  the  heart  is  already 
damaged   by  fibrosis. 

The  correct  diagnosis  may  be  suspected  if  collapse  occurs 
shortly  after  a  very  heavy  meal. 

The  physical  signs  are  obscure,  but  there  may  be  a  great 
increase  of  stomach  resonance  ;  there  is  no  visible  peristalsis, 
but  often  there  is  repeated  unproductive  retching. 

The  symptoms  are  those  of  cardiac  embarrassment. 

The  correct  treatment  is  to  empty  the  stomach  ;  five 
or  six  pints  may  be  recovered,  and  relief  is  often  pro- 
nounced. 

(ii.)  Atonic  or  Non-obstructive  Dilatation  of  the  Stomach 
{Chronic).  This  condition  is  the  result  of  prolonged  chronic 
gastritis,  usually  with  more  or  less  atrophy  and  always  with 
impaired  motility  (continuous  hypersecretion  is  an  infrequent 


344  MEDICAL  DIAGNOSIS 

cause).  Food  is  permitted  to  delay  in  the  stomach  unduly, 
and  gradually  dilatation  of  the  viscus  takes  place.  It  seems 
probable  that  impaired  motility  is  the  most  essential  factor. 

The  symptoms  are  mainly  those  of  flatulent  dyspepsia  ; 
there  is  constant  epigastric  oppression  and  discomfort  with  a 
sense  of  distension,  except  on  the  rare  occasions  when  the 
stomach  is  quite  empty.  The  smallest  amount  of  food 
produces  an  exacerbation  of  these  symptoms,  and  violent 
eructations  are  a  distressing  feature  of  the  case. 

General  neurasthenic  symptoms  are  often  present. 
True  pain  (apart  from  a  sense  of  distension)  is  not  necessarily 
found,  but  may  occur  in  paroxysms  associated  with 
peristaltic  efforts  (possibly  visible)  shortly  after  the  taking 
of  food. 

Vomiting  is  a  prominent  feature  when  any  considerable 
amount  of  dilatation  has  developed  ;  it  occurs  at  infrequent 
intervals  (twenty-four,  thirty-six,  or  forty-eight  hours)  and 
is  of  large  amount  and  frothy  appearance,  while  the  food 
present  may  be  recognised  as  having  been  taken  many  hours 
before.  The  total  acidity  is  variable  ;  often  it  is  slightly 
sub-normal  :  if  high,  active  ulceration  (simple)  may  be 
suspected  ;  if  very  low,  malignant  disease  is  a  possibihty 
unless  achyha  can  be  demonstrated. 

Sarcinse  are  usually  present  in  the  gastric  contents. 

Physical  Signs.  The  important  phj/sical  signs  of  a  dilated 
stomach  are  : — 

(a)  Increase  of  stomach  resonance  to  auscultatory  per- 
cussion (if  necessary,  after  inflation  of  the  organ). 

(6)  Succussion,  or  stomach  splash,  elicited  six  or  more 

hours  after  a  meal. 

(c)  Peristalsis,  if  present,  is  almost  pathognomonic, 
(c?)  Visible    distension   with    obvious   stomach    outline 

(this  is  only  present  in  extreme  cases). 

The  diagnosis  may  be  clinched  by  examination  with  the 
X-rays,  or  by  the  use  of  the  stomach  tube,  which  will  demon- 
strate the  presence  of  residual  contents  when  the  stomach 
should  be  empty. 

(iii.)  Obstructive  Gastrectasis.  This  may  be  simple  or  malig- 
nant. The  greater  number  of  cases  are  due  to  carcinoma  of 
the  pylorus,  but  cicatricial  contraction  during  the  healing 


DISEASES   OF   THE   ALIMENTARY   TRACT      345 

of  a  simple  ulcer  is  not  infrequent.     A  third  group  occurs  as 
Congenital  Hypertrophy  of  the  Pylorus  {vide  infra). 

In  atonic  gastrectasis  the  stomach  wall  is  thinned  and 
feeble  ;  in  obstructive  gastrectasis  it  is,  at  first  at  least, 
vigorous  and  hypertrophied  from  its  attempts  to  overcome 
the  obstruction. 

The  signs  and  symptoms  of  the  actual  dilatation  will  be  the 
same  as  those  described  in  the  previous  section,  but  in  organic 
obstruction  vomiting  is  more  persistent  and  more  regular  ; 
visible  peristalsis  is  common  (reverse  peristalsis  is  patho- 
gnomonic), and  the  pylorus  maybe  palpable.  In  addition, 
the  other  features  of  the  underlying  cause  may  be  present, 
and,  of  course,  the  test  meal  reactions  will  vary  with  the 
pathological  condition. 

(iv.)  Congenital  Hypertrophic  Pyloric  Stenosis.  As  the  name 
implies,  this  disease  is  produced  by  narrowing  of  the  exit 
from  the  stomach  from  muscular  overgrowth  of  the  pyloric 
ring.  It  is  a  congenital  abnormality  and  symptoms  generally 
appear  the  third  or  fourth  week  of  life. 

The  diagnostic  points  are  : — 
(a)  The  age  of  the  patient. 
(6)  The  type  of  vomiting,  which  has  aptly  been  termed 

"  explosive  "  ;  so  vigorous  is  it  that  the  stomach  contents 

are  thrown  a  considerable  distance. 

(c)  Constipation.      After  a  few  days  this  may  become 

absolute,  but  this  of  course  varies  with  the  completeness 

of  the  pyloric  obstruction. 

(fZ)  Visible    gastric    peristalsis,     not    infrequently    of 

reverse  type. 

(e)  A  palpable  pylorus. 

(/)  A  larger  stomach  than  is  usual  for  the  age  of  the 

child  ;  this  can  be  shown  by  gentle  lavage  with  warm  bi- 
carbonate solution. 

Spasm  of  the  Pylorus  may  occur  in  infancy  without  true 
hypertrophy  of  the  pylorus  ;  the  signs  and  symptoms  are 
the  same,  except  that  the  pylorus  is  not  .so  likely  to  be 
palpable.  The  two  conditions  can  only  be  distinguished 
by  the  effect  of  medical  treatment,  which  is  often  successful 
in  spasm,  but  which  rarely  cures  a  case  of  hypertrophic 
«tenosis. 


346  MEDICAL   DIAGNOSIS 

D.  New  Growth.  The  stomach  may  be  affected  primarily 
by  mahgnant  disease,  or  the  growth  may  invade  the 
stomach  by  direct  extension,  as  from  the  head  of  the  pan- 
creas or  elsewhere.  Metastatic  growths  are  rare.  Stomach 
growths  are  piractically  always  carcinomatous  ;  sarcoma 
has  occasionally  been  recorded,  and  very  rarely  adeno- 
myomata  have  been  described. 

The  pylorus  is  the  usual  site  for  new  growth,  next  the 
lesser  curvature,  then  the  cardiac  orifice,  and  lastly  the 
fundus  of  the  stomach. 

It  is  deplorable  that  it  is  still  the  exception  rather  than 
the  rule  for  a  positive  diagnosis  of  malignant  disease  of  the 
stomach  to  be  made  in  the  absence  of  a  palpable  tumour. 
Much  has  been  hoped  for  from  the  chemical  analysis  of  the 
gastric  contents  after  test  meals,  and  much  help  is  often 
afforded  by  these  means  ;  but  the  findings  are,  as  yet, 
not  sufficiently  constant  or  exclusive  in  the  very  early 
cases,  and  it  is  only  the  early  cases  that  can  be  cured  by 
gastrectomy. 

At  the  same  time  many  cases  are  overlooked  because  the 
importance  of  two  or  three  cardinal  symptoms  is  not  suffi- 
ciently recognised.  These  symptoms  are  not,  in  themselves, 
pathognomonic,  but  they  are  sufficiently  striking  to 
warrant  the  employment  of  all  other  available  methods 
of  examination.  When  every  possible  investigation  has 
been  carried  out  a  careful  consideration  of  the  data  thus 
afforded,  together  with  the  history  and  clinical  phenomena, 
will  often  lead  to  exploratory  operation  and  sometimes  to 
successful  excision  of  a  growth  which  otherwise  might  have 
been  treated  symptomatically  till  too  late. 

Especially  unfortunate  are  those  individuals  in  whom 
carcinoma  develops  in  a  chronic  gastric  ulcer.  Often  they 
have  been  known  to  have  gastric  ulceration  for  years,  and 
they  are  treated  again  and  again  for  this  condition  until  the 
presence  of  a  large  mass  simply  compels  the  revision  of 
diagnosis.  As  already  stated,  every  case  of  chronic  gas- 
tric ulcer  should  be  submitted  to  operation  as  soon  as 
diagnosed. 

Early  symptoms  which  should  excite  suspicion  of  a 
possible  gastric  neoplasm  are  : — 


DISEASES   OF   THE   ALIMENTARY   TRACT      347 

(a)  The  occurrence  of  dyspeptic  symptoms  in  a  person 
over  40  years  of  age  who  was  previously  not  afflicted  with 
indigestion. 

(6)  Alteration  in  habits  of  defsecation  in  any  one  over 
40  years  of  age — that  is  to  say,  constipation  in  one  who 
was  not  costive  before,  or  diarrhoea  in  one  habitually 
',;onstipated,  is  often  an  early  sign  of  either  rectal  or 
gastric  carcinoma.  The  rectum  and  sigmoid  can  be 
examined  with  a  sigmoidoscope  and,  if  free,  attention 
can  be  focussed  on  the  stomach. 

(c)  Rapid  loss  of  weight,  combined  with  any  dyspeptic 
symptoms. 

The   signs   and  symptoms   of   gastric   carcinoma   are    as 
follows  : — 

(a)  Cachexia.  This,  of  course,  only  suggests  malignant 
disease  somewhere  ;  it  is,  however,  peculiarly  early  in 
gastric  cancer.  It  is  shown  by  an  earthy  pallor  and  a 
yellow,  inelastic  skin. 

(b)  Palpable  Tumour.  This  is  strongly  corroborative, 
but  is  not  absolutely  pathognomonic,  since  a  pylorus 
bound  by  dense  adhesions  to  the  gall-bladder  will  be 
readily  palpable. 

(c)  Pain.  This  is  a  constant  symptom  ;  it  is  generally 
a  persistent,  dull  ache  in  the  epigastrium  liable  to  exacer- 
bations at  varying  times  after  food. 

{d)  Tenderness.  This  is  very  variable  and  often  con- 
spicuously slight. 

(e)  Vomiting.  This  is  present  in  90  per  cent,  of  all 
cases.  It  is  most  usual  about  two  hours  after  food.  The 
vomited  material  is  important :  meat  is  badly  digested, 
starchy  foods  are  well  digested.  Blood  is  very  often 
present,  rarely  in  large  amount,  and  is  frequently  only 
detected  by  the  occult  blood  test  {vide  p.  331). 

(/)  Melcena.  Blood,  often  in  minute  traces  only,  is 
present  in  upwards  of  1)0  per  cent,  of  all  ca.ses. 

(g)  The  Blood.  A  secondary  ana^nia  is  the  rule,  with  a 
definite  leucocytosis  if  the  growth  is  ulcerating  or  if  there 
arc  many  metastatic  deposits. 

{h)  Fever.  In  late  cases  there  is  an  iuterniittent 
pyrexia,  presumably  due  to  septic  absorption. 


348  MEDICAL   DIAGNOSIS 

(i)  Gastredasis.  This  frequently  develops  if  the  growth 
is  at  the  pylorus  {vide  p.  344). 

(j)  Analysis  of  Gastric  Contents  after  a  Test  Meal. 
Riegel's  or  Fischer's  meal  should  be  employed.  The 
absence  of  free  HCl  is  an  important  sign.  It  happens  very 
early  while  the  total  acidity  is  still  normal,  though  in  later 
cases  as  the  secretion  diminishes  the  total  acidity  faUs 
also.  Though  important,  the  absence  of  free  HCl  is  not 
per  se  conclusive,  since  it  is  also  lost  in  advanced  chronic 
gastritis,  in  achylia,  and  in  pernicious  anaemia.  Achylia 
can  be  shown  by  the  absence  of  pepsin  in  the  gastric  juice 
and  pernicious  anremia  by  the  blood  examination  ;  for 
no  matter  how  closely  the  red  cells  and  haemoglobin  in 
carcinoma  may  occasionally  resemble  those  in  pernicious 
anaemia,  in  carcinoma  there  is  not  a  leucopenia. 

The  presence  of  lactic  acid  is  regarded  by  some  as  almost 
as  important  as  the  absence  of  free  HCl ;  it  is  of  great 
service  in  helping  to  exclude  chronic  gastritis,  since  it  is 
not  found  in  this  condition.  It  may  also  occur  (but  not 
constantly)  in  atony  with  hyperacidity,  and  also  in  atrophy 
with  pyloric  stenosis. 

The  Boas-Oppler  bacillus  is  but  rarely  found  in  any 
non-malignant  disease  of  the  stomach.  Sarcinse  are  very 
rare  in  malignant  disease.  Fragments  of  tumour  are 
of  course  pathognomonic,  but  are  scarcely  ever  found. 
Summary.  In  conclusion  we  may  summarise  the  more 
important  diagnostic  points  : — 

(a)  Rapid  emaciation  and  cachexia  in  persons  over  40. 

(6)  Vomited  material  which  contains  altered  blood 
(coffee-grounds) . 

(c)  The  presence  of  blood  in  the  faeces. 

(d)  Absence  of  free  HCl,  with  the  presence  of  lactic 
acid  and  the  Boas-Oppler  bacillus  after  a  Riegel's  test  meal. 

(e)  Palpable  tumour. 

The  differential  diagnosis    of   gastric  carcinoma  must  be 
made  from  : — 

(a)  Gastric  Ulcer  {vide  p.  342). 
(6)  Chronic  Gastritis  {vide  p.  338). 
(c)  Pernicious  Anaemia  {vide  p.  103). 
(rZ)  Nervous  Achylia  {vide-p-  349). 


DISEASES   OF   THE  ALBIENTARY  TRACT      349 

E.  Disorders  OF  Secretion,  {i.)  Achylia.  As  mentioned 
when  discussing  atrophic  gastritis,  achyha  may  be  an 
accompaniment  of  this  condition  ;  it  may  also  be  a  mani- 
festation of  coincident  gastric  carcinoma.  In  both  these 
types  the  symptoms  of  the  primary  disorder  are  present 
and  the  achyUa  is  a  purely  secondary  affair. 

There  is,  however,  a  form  of  achylia  which  occurs  simply 
as  a  manifestation  of  nervous  instability  ;  it  may  be  per- 
sistent or  paroxysmal  or  may  terminate  spontaneously 
without  obvious  reason.     Only  adults  are  affected. 

The  symptoms  of  achylia  itself  are  variable  ;  they  may  be 
very  slight  in  those  cases  in  which  the  motihty  of  the  stomach 
is  unimpaired  and  the  food  is  passed  rapidly  into  the 
intestine.  Where  the  motihty  of  the  stomach  is  impaired 
there  may  be  a  sense  of  heaviness  and  distension  in  the 
epigastrium  soon  after  taking  food  ;  vomiting  is  uncohimon, 
but  when  present  the  food  is  returned  practically  as  it  was 
swallowed,  except  for  some  starch  digestion  by  the  ptyahn 
of  the  saliva. 

The  diagnosis  is  readily  made  by  a  test  meal  which 
shows  complete  absence  of  HCl  and  also  of  pepsin  and 
rennin. 

(ii.)  Hypersecretion.  This  condition  is  of  the  nature  of  an 
over-active  reflex  action.  It  is  common  in  cases  of  gastric 
ulcer,  and  probably  does  not  occur  apart  from  hyperacidity 
unless  as  a  gastric  crisis  of  tabes. 

Two  forms  are  described — first,  continuous  hypersecre- 
tion (Teichmann's  disease,  or  gastro-succorrhcea),  and 
secondly,  paroxysmal  hypersecretion  (Rosbach's  disease,  or 
gastroxynsis). 

As  a  general  rule  hypersecretion  is  a  symptom  only,  and 
the  objective  features  are  really  those  of  hyperacidity  {vide 
p.  350). 

The  diagnosis  of  hypersecretion  can  be  made  as  follows  : — 
Wash  the  stomach  empty  over  night  and  give  a  test  breakfast 
at  7  a.m.  the  next  morning.  Remove  the  breakfast  in 
forty  minutes.  If  more  than  200  c.c.  are  returned  there  is 
hypersecretion,  j)rovided  that  the  stomach  motility  is  normal 
and  that  there  is  no  pyloric  obstruction. 

In  all  cases  of  paroxysmal  gastroxynsis  it  is  of  the  first 


350  MEDICAL  DIAGNOSIS 

importance  to  exclude  tabes  dorsalis  ;  if  this  can  be  done 
gastric  ulcer  with  pyloric  spasm  may  be  suspected. 

(iii.)  Hyperacidity — that  is  to  say,  more  than  2  per  cent,  of 
acid  in  the  gastric  juice  during  digestion.  Continuous 
hj^Der  acidity  is  practically  equivalent  to  continuous 
hypersecretion. 

Hyperacidity  is  in  itself  very  suggestive  of  simple  gastric 
ulcer. 

The  symptoms  are — a  sense  of  weight  in  the  epigastrium, 
heartburn,  the  eructation  of  acid  mouthfuls  (pyrosis),  and 
sometimes  the  vomiting  of  an  acid  tasting  material.  The 
distressing  symptoms  usually  appear  about  two  hours  after 
a  meal,  are  relieved  by  food  (if  of  a  proteid  nature),  and  are 
promptly  removed  by  alkalies.     The  tongue  is  clean. 

There  is  not  often  any  doubt  as  to  the  presence  of  hyper- 
acidity, but  an  absolute  diagnosis  can  be  made  from  the 
high  acidity  figures  in  the  gastric  contents  either  when 
vomited  or  after  a  test  meal.  It  is  well  to  consider  the  possi- 
bility of  gastric  ulcer  in  any  person  suffering  from  persistent 
hyperacidity,  though  it  is  fairly  frequently  found  as  an 
apparently  simple  neurosis.  Probably  the  gastric  mucous 
membrane  of  such  individuals  is  abnormally  sensitive  to 
reflex  stimulation. 

(iv.)  Hypo-acidity  is  not  likely  per  se  to  cause  symptoms, 
but  when  discovered  by  a  test  meal  analysis  it  is  an  important 
sign  of — chronic  gastritis,  atrophic  gastritis,  and  carcinoma 
of  the  stomach. 

The  repeated  complete  absence  of  HCl  is  only  likely  to  be 
found  in  malignant  disease  and  achj^lia  (whether  nervous  or 
symptomatic).  It  may,  however,  also  be  met  with  in 
pernicious  anaemia. 

F.  Gastric  Neuroses,  (i.)  Anorexia  Nervosa.  More  pro- 
perly this  should  be  considered  as  a  manifestation  of 
hysteria  or  neurasthenia,  since  there  is  no  real  pathological 
condition  of  the  stomach  or  its  juices  except  in,  and  then 
rarely,  achyHa. 

The  complaint  is  practically  limited  to  the  female  sex 
and  is  most  common  between  the  ages  of  20  and  30. 

There  is  complete  lack  of  all  appetite,  and  the  sight  or 
thought  of  any  form  of  food  is  absolutely  repulsive.     A 


DISEASES   OF   THE   ALIMENTARY   TRACT      351 

constant  feature  is  the  immediate  vomiting  (practically 
regurgitation)  of  any  food  that  is  taken.  Starvation  ensues 
and  most  extreme  emaciation  may  be  met  with.  The 
absence  of  any  discoverable  organic  disease  should  suggest 
the  diagnosis. 

The  vomiting  of  pregnancy  and  of  oesophageal  obstruction 
must  be  excluded  {vide  also  p.  321). 

(ii.)  Bulimia  (Excessive  Appetite).  What  constitutes 
bulimia  must  depend  largely  on  the  individual  and  his  mode 
of  life,  but  a  sudden  change  in  the  direction  of  greatly- 
increased  appetite  without  a  corresponding  increase  in  the 
amount  of  exercise  should  arouse  suspicion. 

This  condition  is  most  often  met  with  in  diabetes  mellitus, 
but  may  also  occur  in  Graves'  disease  and  certain  cerebral 
lesions,  of  which  perhaps  the  most  usual  is  epilepsy.  It  may 
also  occur  as  a  pure  neurosis.  ' 

(iii.)  Pica.  The  craving  for  unusual  articles  of  diet  or 
even  for  filthy  material  is  met  with  in  hysteria,  in  children, 
in  imbeciles,  and  in  pregnant  women,  though  in  the  latter 
it  does  not  often  assume  any  more  extreme  degree  than  a 
desire  for  pickles,  acids,  etc. 

In  children  it  is  often  the  expression  of  a  need  for  some 
material  which  is  absent  from  their  allotted  diet  or  present 
in  insufficient  amount  to  fulfil  their  metabolic  requirements. 


VI.  THE  INTESTINES. 

A,  Examination  of  the  Faeces.  A  prolonged  or  elaborate 
examination  of  the  faeces  is  beyond  the  scope  of  the 
practitioner  ;  further,  the  information  gained  by  such  pro- 
cedure is  but  rarely  of  sufficient  value  to  justify  the  inves- 
tigation. 

In  obscure  cases  a  correct  diagnosis  may  sometimes  be 
indicated  by  this  means  alone,  but  as  a  routine  method  it 
is  unnecessary. 

The  following  points,  however,  are  important  and  may 
be  elicited  without  trouble  or  difficulty  : — 

(a)  The    gross    character    of    the    motions,    including 

weight,  size,  frequency,  form,  consistence,  and  colour  ; 


352  MEDICAL  DIAGNOSIS 

also  the  presence  of  blood  or  mucus,  as  well  as  parasites, 

foreign  bodies,  calculi,  or  obvious  undigested  food. 
(6)  The  microscopical  examination  of  portions  of  the 

faeces  may  show  certain  parasites  or  their  eggs,  muscle 

fibres  from  undigested  meat,  starch  granules,  pus  cells 

and  red  blood  cells,  and  fat. 

For  purposes  of  investigation  the  faeces  are  collected  in  a 
covered  vessel  ;  if  they  are  too  solid  they  are  diluted  with 
water  and  they  are  examined  by  passing  them  through  a 
wire  sieve.  Selected  portions  can  be  examined  as  ordinary 
wet  preparations  with  the  microscope. 

The  natural  brown  colour  of  the  faeces  is  largely  due  to 
hydrobilirubin  (reduced  bilirubin)  ;  if  this  is  absent  obstruc- 
tion to  the  bihary  apparatus  is  probable. 

In  health  about  200  grms.  of  faeces  are  passed  daily  ;  of 
this  nearly  one-third  by  weight  is  composed  of  bacteria — 
the  remainder  consists  of  undigested  cellulose,  salts,  and 
small  amounts  of  intestinal  epithelium. 

The  presence  of  muscle  fibres,  starch  granules,  and  much 
fat  indicates  impairment  of  digestiv^e  processes  or  a  con- 
siderable increase  in  the  motility  of  the  intestines. 

The  presence  of  blood  in  the  faeces  is  always  pathological. 
If  it  comes  from  the  rectum  or  descending  colon,  it  is  bright 
red,  and,  especially  if  from  the  rectum,  is  liable  to  coat  the 
outside  of  otherwise  natural  stools.  If  from  the  small 
intestine,  it  is  dark  in  colour  and  intimately  mixed  with  the 
faeces,  unless  the  haemorrhage  is  very  profuse  {e.g.,  some 
cases  of  enteric  fever).  The  higher  up  the  source  of  the 
bleeding  the  darker  do  the  motions  become.  The  passage 
of  blood  and  slimy  mucus  without  any  faecal  matter  is 
almost  pathognomonic  of  either  intussusception  or  volvulus 
of  the  large  gut. 

Any  considerable  amount  of  blood  in  the  faeces  is  obvious 
to  the  naked  eye  ;  small  traces  can  only  be  detected  by  the 
occult  blood  test  {vide  p.  331).  For  this  test  the  patient 
should  be  on  simple  diet,  since  meat  and  even  fish  and  green 
vegetables  give  a  positive  reaction. 

Mucus  in  obvious  amount  shows  catarrh  of  the  intestine — 
of  the  small  gut  if  mixed  with  the  stool  and  of  the  colon  if 
the  faeces  are  coated  with  it. 


DISEASES   OF   THE   ALIMENTARY   TRACT      353 

Pus  is  rarely  found  except  in  a  lesion  of  the  rectum  or 
colon. 

Bacilli.  The  chief  organisms  are  tlie  B.  coli  group  ;  they 
are  mostly  Gram-negative  ;  it  is  noteworthy  that  in  certain 
diseases  associated  with  metabohc  disturbance  {e.g.,  coeliac 
disease)  Gram-positive  bacilli  predominate. 

The  bacillus  typhosus,  the  cholera  vibrio  and  Shiga's 
bacillus  of  dysentery  can  all  be  demonstrated  in  the  stools 
of  patients  suffering  from  these  diseases. 

The  amoeba  of  dysentery  can  also  be  found  in  cases  of 
this  type  of  dysentery. 

Parasites.  A  large  number  of  parasites  have  been  des- 
cribed. The  common  ones  are  tape-worm,  round-worm, 
and  thread-worm.  The  ova  of  various  parasites  can  only 
be  detected  microscopically  and  need  an  expert  knowledge 
for  their  differentiation. 

An  egg  which  it  is  important  to  recognise,  since  its  presence 
is  associated  with  intestinal  haemorrhage,  is  that  of  the 
Bilharzia  haematobium.  Although  this  parasite  is  not 
endemic  in  England,  many  English  people  visit  South  Africa 
and  Egypt  and  may  there  acquire  the  disease. 

The  worm  usually  attacks  the  bladder,  but  sometimes  is 
found  in  the  intestine.  The  eggs  can  easily  be  recognised  ; 
they  are  oval  in  .shape,  about  16  mm.  in  diameter,  and  show 
a  lateral  spint.  When  the  eggs  are  in  the  bladder  the  spine 
is  situated  terminally  {vide  Fig.  34). 

B.  Diarrhcea.  This  usually  indicates  enteritis,  whether 
of  the  small  or  large  gut.  Irritant  matter  may  be  swallowed, 
it  may  be  elaborated  in  the  inte.stines  by  the  action  of 
bacteria,  or  it  may  be  manufactured  elsewhere  and  excreted 
into  the  intestine.  Again,  certain  infections  such  as 
dy.sentery  and  enteric  fever  cause  local  lesions  iji  the  walls  of 
the  intestine,  and  the  iiritation  of  faecal  matter  passing  over 
these  excites  peristalsis  and  so  produces  diarrhcea. 

Diairluea  may  also  be  produced  as  a  (rouipcnisatiou  for 
(liuiinished  activity  of  other  organs,  as  in  kidney  and  liver 
(li.sea.se  ;  under  such  circumstances  many  toxins  are  elimi- 
nated in  the  diarrlueitt  motions  which  would  otherwise  prove 
harmful  to  the  general  system.  It  is  unwi.se  to  check  too 
swiftly  the  diarrhoea  which  often  accompanies  cirrhosis  of 

.M.i».  23 


354  MEDICAL   DIAGNOSIS 

the  liver,  since  watery  evacuations  tend  to  relieve  portal 
congestion. 

Another  cause  of  diarrhoea  is  disturbance  of  the  proper 
nervous  control ;  in  these  cases  the  diarrhoea  is  often  parox- 
ysmal {e.g.,  the  candidate  for  an  examination  or  one  about  to 
run  a  race),  but  a  large  group  of  cases  with  neurasthenia  have 
a  tendency  to  chronic  diarrhoea,  which  often  takes  the  form  of 
mucous  colitis  [vide  p.  368). 

When  lardaceous  disease  affects  the  intestines  there  is 
severe  diarrhoea,  but  the  intestines  are  not  affected  till  after 
the  spleen,  liver,  and  kidneys,  so  that  there  is  ample  evidence 
on  which  to  form  an  accurate  diagnosis. 

Constipation  as  a  cause  of  diarrhoea  must  not  be  forgotten  : 
the  presence  of  scybalous  masses  in  the  large  gut  may  so 
irritate  the  mucous  membrane  as  to  initiate  a  spurious 
diarrhoea  in  which  soft  or  watery  motions  are  passed  ;  but 
all  the  time  the  scybala  which  cause  the  trouble  remain  in 
situ.  A  series  of  large  enemata  wiU  settle  the  diagnosis  of 
such  cases  and  cure  them  at  the  same  time. 

One  of  the  first  signs  of  new  growth  of  the  intestine  or 
stomach  may  be  diarrhoea  (often  alternating  with  constipa- 
tion) ;  hence  the  sudden  onset  of  intermittent  diarrhoea  in 
a  middle-aged  or  elderly  person  requires  the  most  thorough 
investigation. 

In  itself  diarrhoea  is  often  beneficial,  since  it  helps  quickly 
to  eliminate  toxic  matter  from  the  system,  but  continued 
diarrhoea  is  most  exhausting,  and  collapse  (due  to  loss  of 
fluid  from  the  body)  soon  develops  in  the  old,  the  debilitated, 
and  in  children. 

The  exact  appearance  of  the  evacuations  is  not  often  of  any 
particular  help  in  forming  a  diagnosis  ;  in  obscure  cases 
examination  of  the  fseces  (as  indicated  on  p.  351)  may  be  of 
assistance.  For  the  rest  the  following  types  of  motion  are 
found  to  be  associated  with  more  or  less  definite  conditions: — 
The  pea-soup  stool — with  enteric  fever  or  allied  infec- 
tions. 

The  rice-water  stool — -with  Asiatic  cholera. 

Very  frequent  small  stools  consisting  chiefly  of  blood 

and  mucus  and  passed  with  great  pain — with  dysentery. 
Small  stools  coated  with  mucus — with  mucous  colitis. 


DISEASES   OF   THE   ALIMENTARY   TRACT      355 

Foul  green  fiiiid  stools  looking  like  chopped  parsley  and 

often    flecked    with    blood— with    epidemic    enteritis    of 

infancy. 

Bulky  pale  porridge-like  stools — with  coeliac  disease. 

(J.    Constipation,  Intestinal  Stasis,  and  Intestinal  Obstruc 
tion.     The  bowels  of  an  ordinary  healthy  person  should  be 
opened  once  every  day.     Many  persons  habitually  have  two 
motions  daily,  and  three  is  by  no  means  unusual. 

On  the  other  hand,  certain  people  only  have  their  bowels 
opened  every  second  or  even  every  third  day,  and  yet  they 
appear  to  enjoy  perfect  health.  A  few  cases  are  recorded 
when  only  one  motion  weekly  has  not  produced  any 
untoAvard  .symptoms. 

It  is  obvious  that  the  term  "  constipation,"  like  diarrhoea, 
must  only  be  used  after  due  consideration  of  individual 
peculiarities.  ' 

At  the  same  time  it  is  probable  that  those  cases  in  which 
perfect  health  continues  in  spite  of  infrequent  evacuations 
of  the  rectum  are  examples  of  the  adaptability  of  the  par- 
ticular individual  to  unnatural  circumstances  rather  than 
evidence  of  the  advisabihty  of  the  procedure. 

The  normal  stool  is  formed  but  soft  ;  any  undue  hardness 
indicates  constipation,  because  the  consistence  varies  with 
the  amount  of  water  present,  and  if  too  much  water  has  been 
abstracted  it  is  evident  that  the  faeces  have  delayed  too  long 
in  the  large  intestine. 

A  very  constipated  motion  consists  of  extremely  hard, 
dark-coloured  rounded  masses,  often  about  the  size  and  shape 
of  a  walnut. 

As  mentioned  in  the  previous  section,  constipation  may 
be  present  even  while  there  is  apparent  diarrhoea,  since  the 
scybala  may  not  be  passed  themselves  even  though  they 
irritate  the  bowel  sufficiently  to  promote  a  How  of  watery 
mucus  which  is  passed  with  a  certain  proportion  of  faecal 
matter. 

Under  ideal  ccmditicjus  the  rectum  should  always  he 
empty  ;  the  moment  any  faeces  enter  it  the  rectal  reflex  is 
aroused  and  there  is  a  call  to  stool  :  if  tlie  call  is  obeyed,  the 
colon  as  far  as  the  splenic  flexure  or  higher  is  emptied. 
Such  calls  should  never  he   neglecled.      Unfortunately  the 

23—^ 


356  MEDICAL   DIAGNOSIS 

artificial  existences  that  we  are  compelled  to  lead  often 
prevent  lis  from  obeying  the  call  to  stool  ;  as  a  result  the 
reflex  becomes  dulled  and  inactive,  the  faeces  stagnate  in  the 
rectum,  they  lose  water  and  become  hard,  and  in  this 
manner  the  most  common  form  of  constipation  is  developed. 

The  proper  way  to  prevent  this  type  of  constipation  is  to 
encourage  the  boAvels  to  act  at  the  same  hour  every  day  and 
to  let  nothing  interfere  with  this  daily  rite  from  the  earliest 
days  of  childhood. 

Another  common  form  of  constipation  is  due  to  intestinal 
stasis,  especially  in  the  caecum,  ascending  and  transverse  colon. 

The  delay  in  certain  instances  may  be  extreme  (three, 
four,  or  more  days)  and  yet  the  sufferer  may  indignantly 
deny  constipation  because  his  bowels  are  open  every  day — 
so  indeed  they  may  be,  but  the  daily  motions  do  not  even 
begin  to  empty  the  large  gut  as  it  should  be  emptied  and  a 
progressive  accumulation  of  faeces  is  the  result. 

The  cause  of  this  form  of  constipation  is,  usually,  atony 
of  the  muscular  coats  of  the  bowel.  Not  infrequently  in 
these  cases  there  is  hyper-motility  of  the  stomach  and  small 
gut,  so  that  the  chyme  passes  much  too  rapidly  into  the 
caecum  and  is  delayed  there  and  in  the  ascending  colon, 
possibly  to  permit  of  the  completion  vicariously  of  certain 
digestive  processes  which  should  already  have  been  finished 
in  the  ileum.  This  delay  is  achieved  in  part  by  exaggerated 
reverse  peristaltic  waves  in  the  descending  colon,  and  so 
large  gut  stasis  is  initiated.  This  may  terminate  in  pro- 
nounced atony  of  the  muscle  wall  and  is  attended  by  the 
bacterial  elaboration  of  those  toxins,  which,  when  absorbed 
into  the  system,  may  produce  such  diverse  clinical  conditions 
as  pernicious  anaemia,  rheumatoid  arthritis,  pyelitis,  or 
even  septicaemia  should  the  bacilli  themselves  reach  the 
blood-stream. 

Patients  who  suffer  from  intestinal  stasis  of  this  type 
often  present  the  symptoms  of  abdominal  neurasthenia— 
that  is  to  say,  their  attention  is  focusscd  on  their  abdomens  ; 
and  they  accentuate  their  vague  dyspejjtic  troubles  as  well 
as  manifesting  the  more  ordinary  mental  and  physical 
signs.  At  the  same  time  there  is  generally  evidence  of 
auto -intoxication,  as  shown  by  gastric  derangement,  furred 


DISEASES    OF   THE    ALTMEXTARY    TKACT      357 

tongue,  cold  extremities,  pigmentation  of  the  skin,  headaches, 
easy  fatigue,  and,  not  infrequently,  persistent  slight  fever. 

fn  investigating  such  a  case  it  is  important  to  remember 
that  there  may  well  be  an  organic  cause  at  the  bottom  of 
the  ;-,yndrome,  and  it  is  especially  necessary  to  exclude  such 
conditions  as  chronic  or  latent  appendicitis,  ileo-caecal  or 
ileo-colic  bands,  Jacksonian  membranes  and  gastro-colic  or 
gastro-hepatic  adhesions,  as  well  as  the  more  ordinary 
abdominal  diseases,  such  as  duodenal  ulcer  or  gall-stones  and 
pelvic  conditions  in  women. 

Careful  attention  to  the  history  of  the  case,  which  should 
go  back  as  far  as  possible,  combined  with  a  detailed  physical 
examination,  will  often  suggest  such  conditions  as  appen- 
dicitis, duodenal  ulcer,  gall-stones  and  pelvic  disease. 

To  establish  the  Diagnosis  of  intestinal  stasis  and  to  suggest 
the  presence  of  adhesions  it  is  important  to  have  a  series  of 
X-ray  photographs  taken  after  a  bismuth  meal. 

The  progress  of  the  bismuth  can  be  watched  with  a  screen 
from  the  time  it  enters  the  stomach  until  it  leaves  the 
sigmoid,  and  plates  can  be  taken  at  appropriate  intervals. 
The  site  of  delay  can  be  demonstrated,  and  any  kink  or 
band  can  often  be  accurately  localised. 

Partial  Obstruction  in  a  more  definite  sense  than  is 
implied  in  the  previous  paragraphs  necessarily  produces  con- 
stipation sooner  or  later ;  the  motions  become  increasingly 
scanty  and  are  passed  at  infrequent  intervals,  though  there 
may  be  occasional  attacks  of  spurious  diarrhoea.  If  the 
obstruction  is  in  the  rectum  or  sigmoid,  the  motions  often 
assunu'  a  narrowed  calibre  (pipe-stem)  and  may  be  streaked 
with  blood.  A  spastic  condition  of  the  colon  from  irritation 
also  gives  rise  to  pipe-stem  motions,  so  that  their  absolute 
diagnostic  value   is  restricted. 

If  the  obstruction  is  higher  up  Idood  nia\-  be  more  inti- 
mately mixed  with  the  fa?cal  luattci  and  of  darkci  colour, 
while  thi'  nanowing  of  the  fa'ces  may  not  be  apparent 
Ashen  they  are  passed,  though  necessarily  there  is  narrowing 
as  the  actual  obstruction  is  passed  ;  this  may  be  demon- 
strated by  the  X-rays.  Such  obstruction  may  result  from 
new  growth,  bands,  adhesions,  enlarged  glands,  simple 
stricture,  or  impacted  faeces. 


358  MEDICAL   DIAGNOSIS 

New  growth  may  be  in  the  gut  wall,  or  the  gut  may  be 
])ressed  on  by  tumours  in  adjacent  structures. 

The  only  symptoms  of  such  a  condition  of  partial  obstruc- 
tion as  the  above  may  be  a  certain  amount  of  flatulent  dis- 
tension with  general  abdominal  uneasiness,  or  the  patient 
may  complain  of  his  constipation  or  that  he  passes  blood. 

Malignant  disease  may  give  signs  of  cachexia  before  any 
obstruction  is  noted,  but  in  intestinal  cancer  cachexia  is 
often  long  delayed.  In  investigating  such  a  case  the  appear- 
ance of  the  patient  and  a  detailed  history  are  most  important, 
as  is  careful  palpation  of  the  abdomen,  noting  the  presence 
or  absence  of  distension  or  visible  peristalsis,  and  last,  and 
by  no  means  least,  an  examination  of  the  rectum.  If 
necessary  the  sigmoid  can  be  inspected  with  a  sigmoidoscope. 
A  tumour  anywhere  in  the  colon  may  be  faecal  in  nature 
and  should  not  lead  too  quickly  to  a  diagnosis  of  new  growth. 
Faeces  can  often  be  felt  to  pit  on  pressure.  A  series  of 
enemata  will  settle  the  question  by  causing  such  a  mass  to 
disappear. 

Complete  Obstruction,  as  by  new  growth,  bands,  kinks, 
hernia,  etc.,  is,  of  course,  accompanied  by  Absolute  Gonsfipa- 
tion  and  presents  a  sufficiently  striking  clinical  picture. 

In  this  connection  it  is  essential  to  remember  that  a  patient 
(probably  a  woman)  msij  have  no  evacuation  of  the  bowels 
from  constipation  for  two  or  three  weeks  and  yet  there  will 
be  no  urgent  symptoms  at  all  ;  but  mechanical  obstruction 
of  the  gut  lumen  with  interruption  of  the  blood  supply 
invariably  causes  acute  symptoms  within  a  few  hours.  There 
may  have  been  chronic  obstruction  for  months  with  no  acute 
symptoms,  but  the  moment  the  obstruction  is  made  absolute 
the  patient's  condition  becomes  urgent. 

The  outstanding  features  of  acute  obstruction,  as  it  is 
called,  are  : — 

(i.)  Abdominal  Pain,  at  first  colicky  and  paroxysmal, 
but  soon  constant  though  still  liable  to  exacerbations. 
The  maximum  intensity  is  usually  umbilical  or  over  the 
actual  obstruction. 

(ii.)  Distension.  This  develops  rapidly,  but  is  Hmited 
to  the  parts  above  the  obstruction,  so  that  if  the  obstruc- 
tion is  in  the  duodenum  only  the  stomach  itself  is  distended. 


DISEASES   OF   THE   ALIMENTARY   TRACT      350 

The  di.steiision  progre&;ses  from  beloM-  upwards  ;  in  rectal 
obstruction  the  colon  becomes  distended  first  and  may  be 
visible  as  a  horse-shoe  surrounding  the  belly.  Often, 
however,  there  is  a  paralytic  ballooning  of  the  rectum 
below  a  rectal  or  sigmoid  obstruction. 

Central  distension  is  usual  in  small  gut  obstruction.  The 
site  of  the  obstruction  may  often  be  localised  with  con- 
siderable accuracy  by  noting  the  type  of  the  distension. 

(iii.)  Vomiting.  This  is  persistent  until  the  obstruction 
is  relieved  ;  at  first  the  vomited  matter  consists  of  stomach 
contents,  then  bilious  material,  and  lastly  stercoraceous 
matter.  The  lower  the  obstruction  the  longer  is  the 
vomiting  delayed,  though  it  is  usually  a  prominent  feature 
when  once  it  has  appeared.  The  higher  the  obstruction 
the  quicker  does  the  vomiting  appear  and  the  sooner  does 
it  assume  a  fsecal  character.  / 

(iv.)  Ohstruction.  This-  is  absolute  :  flatus  even  does 
not  pass.  It  must  be  remembered,  however,  that  the 
contents  of  the  bowel  below  the  obstruction  may  be 
evacuated  naturally  after  the  obstruction  has  occurred, 
and  will  certainly  be  returned  if  an  enema  be  given. 

(v.)  Peristalsifi.  This  is  oft^n  seen  in  the  distended 
coils  of  gut  before  they  have  become  paralysed.  Reverse 
peristalsis  is  faii'ly  common,  and  is  even  more  pathogno- 
monic of  obstruction  than  the  ordinary  variety. 

(vi.)  Collwpse.  Cold,  damp  skin,  pinched  face,  small, 
quick  pulse,  subnormal  temperature,  and  dry  tongue. 
The  diagnosis  of  the  site  of  obstruction  has  been  outlined 
in  the  preceding  remarks  ;  the  cause  of  the  obstruction  may 
be  impossible  to  determine  :  nevertheless  an  effort  should 
l)e  made  despite  the  fact  that  immediate  operation  is  the 
only  treatment  foi'  acute  obstruction. 

In  babies  acute  obstruction  is  most  frequently  due  to 
int  ussusce])tion  {ride  ]).  IU)5),  in  children  to  tuberculous 
glands  in  the  abdonuMi.  The  presence  of  a  hernia  at  any 
age  would  suggest  strangulation. 

A  history  of  old  tuberculous  peritonitis  or  of  appendicular 
or  of  pelvic  disease  would  suggest  adhesions  from  these 
causes.  In  persons  who  are  more  than  40  years  old 
malignant  disease  becomes  increasingly  probable,  and  since 


300  MEDICAL   DIAGNOSIS 

the  rectum  and  sigmoid  are  the  most  common  situations, 
examination  of  these  structures  often  leads  to  an  accm'ate 
diagnosis. 

An  impacted  gall-stone  Avould  sc^arcely  happen  without  a 
history  of  biliary  colic  and  probably  jaundice. 

D.  Intestinal  Colic.  This  is  produced  by  painful  and 
irregular  contractions  of  the  bowel  (disordered  peristalsis). 

Colic  is  only  a  symptom  and  great  care  must  be  exercised 
in  its  interpretation.  It  may  be  met  with  under  the 
following  circumstances  : — 

(a)  The  ingestion  of  irritating  foodstuffs. 

(6)  Lead  poisoning  and  most  forms  of  irritant  poisoning. 

(c)  In  any  acute  inflamraatory  condition  of  the  bowels, 
such  as  appendicitis. 

(d)  In  intestinal  obstruction,  from  whatever  cause. 

(e)  After  certain  purgatives. 
(/)  In  peritonitis. 

Diagnosis.  The  presence  of  diarrhoea  or  constipation 
accompanying  the  colic  is  of  importance,  as  diarrhoea 
excludes  acute  obstruction  and  is  rather  against  acute 
inflammatory  processes.  Lead  poisoning  is  accompanied 
by  constipation,  but  should  give  its  own  special  signs.  A 
normal  pulse  and  temperature,  and  an  absence  of  all  shock 
as  well  as  a  normal  white  cell  count,  are  in  favour  of  simple 
colic.  The  history  of  Avhat  has  recently  been  eaten  is 
naturally  of  great  importance,  but  may  be  very  misleading. 

In  distinguishing  between  simple  colic  and  "  the  acute 
abdomen  "  stress  may  be  laid  on  two  features,  namely,  the 
attitude  of  the  patient  and  his  pulse.  In  simple  colic  the 
patient  writhes  and  wriggles  as  the  spasms  seize  him  ;  in 
the  ac\ite  abdomen  he  lies  very  still  on  his  baric  and  often  has 
one  or  both  legs  drawn  up.  In  colic  the  pulse  is  quiet  and 
slow,  except  during  the  paroxysms  :  in  the  acute  abdomen 
the  pulse  generally  gets  increasingly  rapid  and  wiry. 
Further,  in  simple  colic  the  abdomen  is  quite  soft  between 
the  spasms. 

The  characteristic  situation  and  distribution  of  the  pain 
in  renal  and  biliary  colic  {vide  p.  397  and  p.  456)  should 
prevent  these  being  mistaken  for  simple  intestinal  colic. 

E.  Aifections  of  the  Duodenum,     (i.)  Catarrhal  Duo- 


DISEASES   OE   THE   ALIMENTARY   TRACT      861 

DENiTis.  This  is  likely  to  occur  whenever  there  is  gastritis, 
and  its  symptoms  may  be  masked  by  those  of  the  latter. 
Bile-stained  voinil  indicates  that  the  inflammation  has 
]jassed  through  the  pylorus. 

Duodenal  inflammation  is  of  special  interest,  since  it  is  pro- 
bable that  it  is  a  necessary  precursor  to  any  ascending  infec- 
tion of  the  bile  passages.  Gall-stones  are  produced  in  this 
manner.  Catarrhal  jaundice  maj-  possibly  result  from  the 
blocking  of  the  opening  of  the  ampulla  of  Vater  by  the  exces- 
sive mucus  produced  by  duodenal  catarrh  {vide  also  p.  383). 

(ii.)  Duodenal  Ulcer.  The  pathology  of  the  peptic 
duodenal  ulcer  is.  in  the  main,  similar  to  that  of  gastric 
ulcer.  Men  are  very  much  more  frequently  affected  than 
women,  and  the  ordinary  age  incidence  is  25  to  50  years. 

Perforation   occurs   relatively    more   frequently    than   in 
gastric  ulcer,  and  is  attended  by  a  much  higher  mortality 
even  when  an  operation  is  undertaken  without  delay. 
The  Symptoms  and  Signs  of  duodenal  ulcer  are  : — 

(a)  General  slight  dyspeptic  symptoms.  These  are 
attributable  to  the  hyperchlorhydria  which  seems  to  be 
constantty  present. 

(6)  Epigastric  Pain.  This  occurs  in  bouts,  is  most 
usual  three  to  four  hours  after  a  meal,  is  promptly  relieved 
by  food  and  gradually  by  alkalies,  and  includes  the  right 
hypochondrium  more  than  gastric  ulcer  does. 

Sometimes  there  are  both  pain  and  tenderness  over  the 
right  lower  ribs  behind. 

(r.)  Tenderness.  This  is  characteristically  situated  over 
a  small  area  to  the  right  of  the  middle  line  :  the  maximum 
intensity  is  often  at  the  junction  of  the  lower  and  middle 
thirds  of  a  line  joining  the  Jimbilicus  with  flic  tip  <»f  the 
ninth  rib. 

{(I)  (hiinneous  JJypercesthesia  is  scmictimes  present  omt 
the  same  area  as  the  tenderness. 

(e)  Rigiditij.  There  maybe  moic  or  less  ligidity  of  the 
upper  segment  of  the  right  rectus  abdominis  muscle. 

(/)  Vomiting.  Unless  the  ulcer  is  just  by  the  pyloric 
ridge,  vomiting  is  uniisual. 

The  same  applies  to  hamiatemesis. 

{g)  Melcena.     The  passage  of  daik   1>Io(hI    p(>r  lectiim 


362  MEDICAL   DIAGNOSIS 

intimately  mixed  with  the  faeces,  if  no  other  cause  can  be 
made  out.  is  strongly  suggestive  of  duodenal  ulcer. 

The  haemorrhage  may  be  very  slight  and  may  require 
the  occult  blood  test  {vide  p.  331)  for  its  recognition.  On 
the  other  hand,  very  grave  anaemia  may  be  caused  in  this 
manner. 

(h)  In  nearly  every  case  a  test  meal  gives  high  acid 
values,  even  higher  than  in  gastric  ulcer. 
Duodena]  ulcer  must  be  distinguished  from  :— 

(1)  Gastric  Ulcer  {vide  p.  343). 

(2)  Chronic  Gastritis  is  suggested  by  morning  sickness, 
furred  tongue,  much  mucus  after  gastric  lavage,  flatulency, 
lack  of  localised  tenderness,  severe  pain  or  melaena,  and 
the  fact  that  food  does  not  markedly  relieve  the  distress. 

(3)  Gall-Stones.  Biliary  colic  is  usually  more  severe 
than  the  pain  of  duodenal  ulcer;  it  is  definitely  situated 
in  the  right  hypochondrium  and  goes  through  to  the 
right  shoulder-blade.  The  pain  is  definitely  paroxysmal, 
and  though  exacerbations  may  occur  about  three  to 
four  hours  after  food,  they  do  not  constantly  do  so 
and  they  are  not  relieved  by  alkalies  or  by  food.  The 
abdominal  tenderness  is  higher  up  toAvards  the  point 
of  the  ninth  rib.  Jaundice  is  frequent,  and  there  is  no 
melaena. 

(4)  Appendicitis.     There  is  no  hunger  pain,  the  lower 
rectus  is  rigid,  the  pain  is  usually  traceable  down  to  the 
iliac  fossa  even  in  those  cases  in  which  its  maximum  inten- 
sity is  above  the  umbilical  level.     There  is  no  melaena. 
(iii.)  Other  Ulcerative  Conditions  of  the  Duodenum. 

Duodenal  ulcers  may  be  found  in  the  following  conditions  : — 

(1)  Bright'' s  Disease.  Examination  of  the  renal  system 
may  suggest  this  cause  for  melaena.  In  albuminuric 
idceration  of  the  intestine  the  duodenuin  is  the  most 
common  site. 

(2)  Leukcemia,  Pernicious  A^icemia,  and  Purpura  do 
not  cause  ulceration  in  the  duodenum  more  frequently 
than  in  the  rest  of  the  small  gut,  and  not  so  frequently  as 
in  the  large  intestine. 

(3)  Gall-Stones.  These  may  ulcerate  into  the  duo- 
denum. 


DISEASES    OF   THE   ALIMENTARY   TRACT      363 

(4)  Carcinoma.  This  may  develop  in  a  chronic  peptic 
ulcer,  or  it  may  spread  from  a  primary  growth  of  the  head 
of  the  pancreas,  of  the  common  bileduct,  or  of  the  gall- 
bladder. 

(5)  After  Extensive  Burns.  Duodenal  ulcers  have  been 
recorded.  Examination  of  post-mortem  records  has  con- 
vinced us  that  this  cause  must  be  extraordinarily  rare 
nowadays,  though  probably  when  buins  weiv  kept  less 
aseptic  the  proportion  was  higher. 

F.  Certain  Special  Forms  of  Intestinal  Disease,  (i.)  Acute 
Enteritis.  This  is  usually  produced  by  some  indiscretion  of 
diet,  especially  by  eating  tainted  food.  The  stomach  is 
often  involved  also,  and  then  the  term  "  gastro- enteritis  " 
is  more  accurate. 

Apart  from  food,  acute  enteritis  is  produced  by /many 
poisons,  especially  arsenic  and  antimony,  and  the  beneficial 
action  of  a  lai'ge  number  of  purgatives  is  the  direct  result 
of  the  mild  enteritis  caused  by  the  drug. 

Debilitated  individuals  are  prone  to  attacks  of  enteritis 
from  causes  whicli  liave  no  effect  on  healthy  persons. 

Certain  diseases- -e.,7.,  exophthalmic  goitre  and  Bright's 
disease — are  liable  to  be  com})licated  by  severe  enteritis. 

Some  apparently  healthy  persons  seeui  to  possess  idio- 
syncrasies for  certain  articles  of  food,  and  when  they  eat 
such  things  always  develop  enteritis.  These  cases  frequently 
have  urticaria  also  ;  possibly,  therefore,  this  type  of  enteritis 
is  due  to  urticaria  on  the  bowel  wall. 

The  severity  of  ordinary  ent«ritis  such  as  results  in  healthy 
persons  from  unsuitable  food  varies  very  much  with  the  age 
of  the  patient.  The  attack  is  always  of  more  serious 
import  in  young  children  than  in  older  persons. 

Enteritis  which  results  from  tainted  food  may  be  of  a 
relatively  simple  form,  or  it  may  be  due  to  certain  alkaloidal 
products  of  bacterial  action  known  as  ptomaines.  Some 
fish,  for  example  mussels,  develop  ptomaines  physiologically 
at  certain  seasons  of  the  year.  The  enteritis  caused  by 
])tomaine  poisoning  is  always  severe,  and  the  ])rognosis 
seems  to  depend  on  three  factors  : — 

(a)  The  amount  and  nature  of  the  ptomaine  taken. 
(6)  The  question  (jf  whether  vomiting  occurs  early  or 


364  MEDICAL   DIAGNOSIS 

late,  and  so  of  wliether  most  of  tlie  poisons  are  expelled 

before  absorption. 

(c)  The  personal  equation,  which  appears  to  be  a  thing 

quite    apart    from    our    understanding,    since    two    quite 

healthy  people  maj'  eat  the  same  amounts  of  the  same 

tainted  food  and  one  may  die  while  the  other  may  suffer 

only  the  most  trifling  inconvenience.     In  fatal  cases  the 

onset  of  symptoms  is  usually  delayed  for  about  thirty-six 

hours  after  taking  the  food. 

The  symptoms  of  simple  acute  enteritis  vary  very  much 
in  their  intensity  :  in  ordinary  cases  colicky  pains  in  the 
abdomen  accompanied  by  diarrhoea  are  all  that  are  to  be 
observed.    If  gastritis  co-exists  there  will  be  vomiting  as  well. 

The  motions  vary  somewhat  according  as  to  whether  the 
large  or  small  intestine  is  chiefly  affected.  In  a  small-gut 
enteritis  there  is  often  partly-digested  food  ;  in  a  large-gut 
affection  there  is  much  slimy  mucus.  In  both  cases  the 
motions  become  increasingly  watery  as  the  disease  advances. 

When  all  the  irritating  material  has  been  exj^elled  the 
symptoms  gradually  subside. 

In  more  acute  cases  the  diarrhoea  and  sickness  are  so 
severe  that  collapse  quickly  ensues,  with  pinched  features, 
rapid,  feeble  pulse,  and  subnormal  temperature. 

Such  cases  are  particularly  likely  to  occur  in  hot  weather, 
and  are  perhaps  due  to  abacillary  infection  (Cholera  Nostras). 
Recovery  when  the  intoxication  has  run  its  conrse  is  just 
as  rapid  as  Avas  the  collapse  at  the  onset. 

In  true  ptomaine  poisoning  severe  symptoms  are  commonly 
delayed  for  at  least  twenty-four  to  thirty-six  hours. 

(ii.)  Epidemic  Enteritis  of  Infants.  As  stated  in  the 
previous  section,  simple  acute  enteritis  due  to  improper 
feeding  is  a  much  more  severe  affection  in  young  children 
than  in  adults. 

Epidemic  Enteritis  is,  however,  quite  a  different  mattei'  ; 
it  is  almost  certainly  a  speciflc  infective  disease,  though 
quite  possibly  more  than  one  individual  organism  may  be 
capable  of  producing  it.  The  intestinal  flora  is  so  diverse, 
that  hitherto  these  organisms  have  not  been  identified  with 
precision. 

The  determining  factors  in  the  production  of  epidemic 


DISEASES   OF   THE   ALIMENTARY   TRACT      365 

enteritis  are — hot  weather,  flies,  dust,  and  the  contamination 
of  milk  and  feeding-bottles.  When  once  started  the  infec- 
tivity  is  great,  and  even  in  hospital  wards,  where  the  utmost 
care  is  exercised,  the  disease  often  spreads  from  bed  to  bed 
with  alarming  rapidity. 

In  London  the  disease  seems  to  be  diminishing  steadily  ; 
f<here  has  been  no  bad  epidemic  since  1906  and  1907.  This 
may  perhaps  be  explained  as  follows  : — There  have  not 
been  very  hot  summers  of  late,  the  science  of  infant  feeding 
among  the  poor  has  made  great  strides,  and  lastly,  with 
the  enormous  increase  of  motor  traffic  and  consequent 
decline  in  /ior6'6 -drawn  vehicles,  flies,  dust,  and  road  dirt 
have  greatly  diminished. 

The  patients  are  mostly  infants  who  are  being  artificially 
fed ;  young  chikh'en  up  to  three  and  four  may  also  be  affected, 
but  in  them  the  infection  is  not  so  severe. 

Two  types  of  the  disease  maybe  recognised — the  afebrile 
and  the  febrile.  In  either  the  child  may  die  within  twenty- 
four  hours  of  the  first  symptom,  but,  on  the  whole,  the 
febrile  form  with  a  temperature  of  103°  to  105°  is  even  more 
quickly  fatal  than  the  other. 

The  symptoms  are  diarrhoea  with  frequent  foul,  green, 
watery  stools,  and  vomiting.  Blood  may  often  be  present 
in  the  motions.  Infants  cannot  stand  the  loss  of  much 
fluid  ;  they  quickly  become  shrunken  and  collapsed  and 
die  from  exhaustion.  All  grades  of  the  disease  are  met  Avith, 
and  in  the  more  chronic  forms  the  outlook  is  more  hopeful. 

The  diagnosis  presents  no  difficulty  ;  the  passage  of 
slimy  motions  streaked  with  blood  may  suggest  intussus- 
ception, but  in  the  latter  there  is  no  faecal  matter  and  a 
tumour  can  be  felt  in  the  abdomen. 

(iii.)  Acute  Intussusception^ or  invagination  of  part  of  the 
intestine  into  itself,  occurs  principally  in  children  from  six 
months  to  two  years  old. 

The  ordinary  form  of  intussusoej)tion  is  the  iloo-(!olic, 
1mi<  soinctimes  ileo-ca'cal  or  ca'co-colic  forms  may  oc(!ur. 

T'he  symptoms  are  those  of  acute  intestinal  obstruction  ; 
paroxysmal  abdominal  pain,  jjossibly  with  vomiting,  and  the 
speedy  disappearance  of  all  faecal  matter  from  the  motions, 
which  soon  consist  entirely  of  blood  and  slimy  mucus.     In 


366  MEDICAL   DIAGNOSIS 

eighteen  to  twenty-f our  hours  distension  develops  and  vomit- 
ing becomes  more  frequent.  In  the  early  stages  shock, 
though  it  is  apparent  to  the  careful  observer,  need  not  be 
marked.  The  intussuscepted  portion  of  gut  can  nearly 
always  be  felt  as  a  tumour  (frequently  sausage -shaped) 
within  the  abdomen  ;  sometimes  it  has  travelled  so  far 
round  the  colon  that  it  can  be  felt  per  rectum,  or  it  may  even 
present  at  this  orifice. 

Most  often  the  tumour  is  situated  in  the  right  hah  of 
the  abdomen  ;  occasionally  it  gets  tucked  up  under  the 
liver,  and  is  then  hard  to  feel. 

We  believe  that  in  all  cases  the  tumour  can  be  felt  if  the 
abdominal  walls  are  relaxed  ;  if  they  are  rigid  an  anaesthetic 
must  be  given. 

The  appreciation  of  the  fact  that  an  abdom.inal  mass  can 
be  palpated  is  of  the  first  importance,  for  it  sometimes 
happens  that  the  passage  of  blood  is  delayed  for  twelve  or 
even  eighteen  hours,  and  every  hour  is  of  value  if  the  child's 
life  is  to  be  saved.  At  least  80  per  cent,  of  the  patients 
recover  if  they  are  operated  on  within  eighteen  to  twenty 
hours. 

Another  point  of  diagnostic  value  is  the  fact  that  babies 
who  get  intussusception  appear  to  be  unusually  healthy  and 
robust.     It  is  more  common  in  boys  than  in  girls. 

Intussusception  must  not  be  mistaken  for  : — 
Enteritis  {vide  p.  365). 
Henoch's  Purpura  {vide  p.  166). 

(iv.)  Coeliac  Disease.  This  disease  develops  in  children 
between  the  ages  of  one  and  three  years.  The  principal 
sign  is  the  passage  of  numerous  bulky,  offensive,  pale- 
coloured  motions,  which  are  often  likened  to  porridge  by  the 
parents.  The  patients  waste  steadily  and  show  great 
muscular  weakness,  and  j^et  no  organic  lesion  can  be  dis- 
covered. Tetany  is  an  occasional  complication,  and  infan- 
tilism is  sometimes  a  sequel  in  severe  cases.  The  course 
tends  to  be  chronic  and  relapses  are  common. 

The  disease  appears  to  result  from  an  inability  properly 
to  digest  fats  and  starches  ;    in  some  cases  (but  not  all) 
there  is  a  notable  excess  of  unaltered  fat  in  the  faeces. 

The  chief  difficulty  in  the  diagnosis  of  coeliac  disease  is 


DISEASES   OF   THE   ALIMENTARY   TRACT      :j67 

to  eliminate  tuberculous  peritonitis  or  tuberculosis  of  tiie 
mesenteric  glands. 

The  character  ot"  the  motions,  as  described  above,  is  the 
most  important  feature. 

The  appearance  of  the  abdomen  is  also  important,  for 
there  are  neither  ascites,  masses  of  omentum,  nor  palpable 
glands. 

The  special  tests  for  the  diagnosis  of  tuberculosis  are  of 
value  in  these  cases. 

The  therapeutic  test  is  also  of  value,  for  the  benefit  shown 
by  many  cases  of  coeliac  disease  from  a  diet  which  consists 
almost  entirely  of  raw  minced  meat  or  raw  meat  juice  is 
striking. 

(v.)  Hirschsprung's  Disease  (Idiopathic  Dilatation  and 
Hypertrophy  of  the  Colon).  This  is  a  congenital  affection 
of  unknown  causation.  The  principal  features  are  obstinate 
constipation  and  a  manifestly  dilated  colon.  As  in  gross 
dilatation  of  other  viscera,  tetany  is  a  not  uncommon  com- 
plication. 

]\rany  children  with  this  disease  show  imperfect  develop- 
ment, or  even  infantilism. 

The  most  urgent  danger  is  acute  intestinal  obstruction. 
The  diagnosis  depends  on  the  presence  of  obstinate 
constipation  from  birth,  with  a  soft  but  enormously  distended 
belly,  in  which  the  huge  colon  is  usually  very  apparent. 
The  percussion  note  over  the  colon  is  tympanitic,  and  peri- 
stalsis can  frequently  be  observed. 

(vi.)  Such  specific  infective  diseases  of  the  intestines  as 
enteric  fever,  tuberculous  enteritis,  dysentery,  cholera,  and 
the  gastro-intestinal  form  of  influenza  are  considered  else- 
where. 

(vii.)  Ulceratii'e  Colitis.  It  seems  artificial  and  unneces- 
sary to  distinguish  between  chronic  dysentery  and  ulcerative 
colitis,  since  pathologically  the  lesions  are  identical  and 
primary  ulcerative  colitis  is  certainly  an  infective  process 
even  though  it  may  n(^t  be  due  to  any  of  the  specific  organisms 
known  to  be  responsible  for  acutt^  dysentery. 

Ulcerative  colitis  may,  however,  occur  as  a  manifestation 
or  complication  of  certain  diseases,  of  which  the  most 
imi)ortant    are    ISrights    disease,    pernicious    auiemia,    and 


368  MEDICAL   DIAGNOSIS 

leukaemia,  or  occasionally  tuberculosis  and  septicaemia. 
Hence  in  investigating  a  case  of  ulcerative  colitis  it  is  first 
necessary  to  exclude  the  above  diseases. 

Diagnosis.  The  mere  diagnosis  of  ulcerative  colitis  is 
usually  obvious,  since  diarrhcBa  with  tenesmus  and  the 
passage  of  red  blood  and  slimy  mucus  must  mean  an 
ulcerative  process  in  the  large  gut.  At  the  same  time  there 
is  progressive  emaciation,  colicky  abdominal  pain,  and  more 
or  less  constant  tenderness  over  the  colon,  which  is  most 
marked  in  the  sigmoid  and  cajcal  regions.  There  may  be 
severe  toxaemia,  and  pyrexia  is  the  rule. 

A  careful  examination  of  the  rectum  and  sigmoid  with  a 
finger  and  the  sigmoidoscope  will  eliminate  such  conditions 
as  carcinoma,  fistula,  or  simple  septic  proctitis,  and  the  sig- 
moidoscope (which  must,  however,  be  used  with  the  utmost 
gentleness)  will  usually  show  definite  ulcerated  areas. 

If  as  the  result  of  all  possible  clinical  investigations  it 
seems  certain  that  the  case  is  one  of  primary  ulcerative 
colitis,  it  is  worth  while  endeavouring  to  isolate  some 
organism  from  the  faeces  which  may  be  responsible. 

This  proceeding  is  very  uncertain,  but  plate  cultures  may 
show  some  organism  {e.g.,  the  pneumococcus)  which  is 
normally  absent,  or  some  normal  inhabitant  may  be  present 
in  excess.  In  the  latter  case  the  patient's  opsonic  index 
may  be  taken  in  respect  of  the  suspected  organisms  and  com- 
pared with  that  of  a  healthy  person.  A  distinct  difference 
in  the  readings  would  justif}^  the  use  of  an  autogenous 
vaccine. 

(viii.)  Mucous  Colitis.  A  condition  characterised  by  an 
excessive  secretion  of  mucus  in  the  large  intestine  and  the 
consequent  passage  of  this  in  the  motions.  At  the  same  time 
the  large  gut  isi  rritable  and  liable  to  spasm,  so  that  painful 
contractions  of  the  colon  are  common.  Very  rarely  a  little 
blood  may  be  noticed  in  streaks  on  the  mucus. 

The  etiology  of  mucous  colitis  is  ob.scure  ;  in  itself  it  can 
only  be  a  symptom,  and,  since  many  sufferers  from  neuras- 
thenia also  have  mucous  colitis,  some  authorities  regard  it 
as  a  pure  neurosis. 

At  the  same  time  there  is  no  doubt  that  in  a  large  pro- 
portion  of   cases   there   is    an   organic  foundation   for  the 


DISEASES   OF   THE   ALIMENTARY   TRACT      f^GO 

condition,  and.  in  investigating  a  case  of  mucous  colitis 
every  effort  should  be  made  to  discover  the  organic  lesion 
if  one  be  present. 

Mucous  colitis  is  more  common  in  women  than  in  men. 
This  can  possibly  be  explained  by  the  greater  frequency 
of  constipation  in  the  female  sex,  for  constipation  either 
]H'ecedes  or  accompanies  mucous  colitis  in  a  large  majority 
of  instances.  Frequently  there  is  habitual  constipation  with 
an  attack  of  p.seudo-diarrhoea  every  three  or  four  days, 
during  which  much  mucous  is  passed  ;  sometimes  a  mucinous 
cast  of  a  portion  of.  intestine  can  be  recognised.  Even 
during  the  periods  of  constipation  the  small  hard  scybala 
are  often  coated  with  mucus. 

The  patient  is  generally  definitely  hypochondriacal,  and. 
because  of  the  as.sociated  abdominal  pain  and  disco>nfort. 
has  ohen  convinced  herself  that  she  is  a  martyr  to  dyspepsia 
and  has  curtailed  her  diet  so  greatl}'^  as  to  impair  her  nutri- 
tion. 

Test  meals  usually  show  a  perfectly  healthy  gastric 
secretion.  Associated  conditions  may  be  a  movable  kidney 
or  general  visceroptosis,  and  not  infrequently  a  colon 
bacilluria. 

The  most  important  organic  lesion  which  may  produce 
mucous  colitis  is  chronic  appendicitis  ^vith  or  without 
adhesions  ;  next  to  this  adhesions  about  the  hepatic  or 
splenic  flexures  of  the  colon,  round  the  pelvic  colon,  or 
across  the  cseco-colic  junction.  The  precise  manner  in 
which  these  conditions  cause  mucous  colitis  is  uncertain  ; 
possibly  the  explanation  is  partly  that  they  favour  consti- 
pation and  intestinal  stasis  and  partly  that  by  interfering 
with  the  proper  peristaltic  movements  of  the  colon  this 
viscus  is  rendered  irritable  and  so  responds  abnormally  to 
the  nervous  stimuli  it  receives,  the  visible  result  of  which 
is  excess  of  mucus. 

The  diagnosis  of  bands  and  adhesions  has  been  considered 
l)riefly  on  p.  357 ;  the  diagnosis  of  chronic  appendicitis 
depends  largely  on  the  liistoiy  of  acute  or  subacute  attacks 
(possibly  after  an  interval  of  many  years)  and  the  presence 
of  deep  tf^nderness  in  the  right  iliac  fossa.  Jiot  ?\ecessarily 
constant.     Further,    in    chronic    appendicitis   of    this    type 

M.i».  24 


370  MEDICAL   DIAGNOSIS 

reflex  gastric  disturbance  (such  as  vomiting  or  other  dys- 
peptic phenomena)  is  often  present. 

No  case  of  mucous  colitis  should  be  labelled  as  simple  or 
neurotic  till  every  effort  has  been  made  to  exclude  definitely 
these  possible  organic  causes. 

VII.  THE  PERITONEUM. 

A.  Ascites.  The  presence  of  fluid  in  the  peritoneal  cavity 
is  only  a  symptom  of  some  underlying  disease. 

Peritoneal  effusions  may  be  serous  or  purulent,  but  the 
term  "  ascites  "  is  restricted  to  the  simple  variety,  because 
a  punilent  effusion  gives  rise  to  a  totally  different  clinical 
picture  with  the  signs  and  symptoms  of  acute  peritonitis  and 
requires  immediate  surgical  interference.  At  the  same  time 
it  is  possible  that  in  the  majority  of  cases  of  ascites  there  is  a 
certain  amount  of  chronic  peritonitis  as  well,  since  it  is 
difficult  to  produce  ascites  experimentally  in  animals  by 
simple  obstruction  to  the  venous  return  from  the  portal 
system. 

The  more  common  diseases  in  which  ascites  is  found 
are  : — 

(i.)  Myocardial  insufficiency  of  the  right  heart,  whether 
due  to  cardiac  fibrosis,  left-sided  valvular  disease,  or  to 
chronic  pulmonary  disease. 

(ii.)  Acute  or  chronic  parenchymatous  nephritis, 
(iii.)  Cirrhosis  of  the  liver  (portal  type), 
(iv.)  Perihepatitis, 
(v.)   Tuberculosis  of  the  peritoneum, 
(vi.)  Diffuse    carcinomatosis    or     sarcomatosis    of    the 
peritoneum. 

(vii.)  New  growth  obstructing  the  portal  vein  (ascites 
not  inevitable). 

(viii.)  Thrombosis  of  the  portal  vein  (ascites  not  inevit- 
able). 

(ix.)  Rupture  of  an  ovarian  cyst  (especially  the  prohf crat- 
ing papillary  ovarian  cyst). 

Sometimes  the  fluid  instead  of  being  serous  in  appearance 
is  milky  or  opalescent  :  the  milkiness  has  sometimes  been 
shown  to  be  due  to  intraperitoneal  rupture  of  the  recepta- 


DISEASES   OF   THE    ALniEXTARY   TRAfT      371 

culum  chyli  or  the  lymphatic  duct  and  so  to  depend  on  the 

presence  of  true  fat  globules  (chylous  ascites),,  but  in  other 

cases  it  is  due  to  certain  lipoids  the  origin  of  which  is  obscure. 
Filaria  sanguinis  hominum  may  cause  chylous  ascites. 
The  fluid  may  be  free  in  the  peritoneum  or  occasionally 

it  may  be  encysted  or  loculated. 

Loculated    ascites    suggests    tuberculosis    or    malignant 

disease,  but  sometimes   occurs   as   the   result  of  frequent 

"  tappings." 

The  positive  diagnosis  of  free  fluid  in  the  peritoneum  is 

usually  easy  and  is  based  on  the  following  signs  : — 

(i.)  Increasing  abdominal  size  with  a  maximum  girth 
at  or  about  the  level  of  the  umbilicus  ;  in  extreme  cases 
the  umbilicus  is  flattened  out  from  within. 

(ii.)  An  area  of  dulness  to  percussion  which  shifty  with 
changes  of  posture.  When  the  patient  is  half  sitting  up 
there  is  a  horse-shoe  of  dulness  over  the  abdomen  with  the 
horns  of  the  horse-shoe  pointing  up  in  the  flanks.  This 
dulness  above  the  pubes  and  each  flank  is  important,  and 
if  the  patient  now  turns  on  to  one  side,  the  flank  which  is 
raised  off  the  bed  becomes  resonant,  while  there  is  a 
deeper  band  of  dulness  than  before  in  the  other  flank. 

(iii.)  A  fluid  thrill  can  be  felt  if  the  flat  of  the  fingers 
be  laid  on  one  dull  flank  and  the  opposite  dull  flank  be 
sharply  tapped  with  the  fingers  of  the  other  hand.  In 
performing  this  test  the  vibrations  of  the  abdominal  wall 
and  intraperitoneal  fat  should  be  cut  off  by  pressure  in 
the  mid-hne  of  the  patient's  abdomen  with  the  ulnar 
border  of  an  assistant's  hand.  It  is  said  that  there  may 
be  too  much  fluid  sometimes  for  a  thrill  to  be  perceived  ; 
we  have  not  seen  such  a  case. 

(iv.)  The  presence  of  a  central  or  upper  central  area  of 
resonance,  due  to  the  floating  upwards  of  the  gas-contain- 
ing intestine. 

(v.)  The  .sensation  of  displacing  fluid  if  sharj)  dip])ing 
movements  are  made  with  the  fingers  on  to  the  liver. 
A  careful  observer  can  hardly  mistake  free  fluid  for  any 

other   condition.     The   following   ])ossible   sources   of  error 

may    be   mentioned,  though   they   aic   iii(»ic  ;i])])li('al)lo    io 

encysted  ascites  : — 

24-2 


372  MEDICAL   DIAGNOSIS 

(i.)  A  Full  Bladder.  This  causes  a  central  dull  area, 
and  micturition  or  the  passage  of  a  catheter  wiU  prevent 
mistake. 

(ii.)  Ovarian  Cyst.  The  dull  area  is  central  or  a  little 
to  one  side  of  the  mid -line.  The  flanks  are  resonant  ; 
the  maximum  girth  is  below  the  umbilicus.  A  pelvic 
examination  may  assist  ;  but  in  so  far  as  an  ovarian  cyst 
will  rise  out  of  the  pelvis  as  it  grows  in  size  a  pelvic 
examination  may  be  negative,  and  under  these  circum- 
stances an  ovarian  cyst  may  be  clinically  indistinguish- 
able from  encysted  ascites,  though  it  should  not  be  mis- 
taken for  free  fluid.  Further,  it  must  be  remembered 
that  an  ovarian  cyst  may  rupture,  so  that  there  may  be 
free  fluid  plus  ovarian  cyst,  and  this  possibility  should 
always  be  borne  in  mind  where  the  fluid  is  present 
in  a  young  woman  who  shows  no  primary  cardiac  or 
renal  trouble  and  in  whom  the  history  does  not  favour 
tuberculous  peritonitis. 

(iii.)  A  hydatid  cyst  may  simulate  ascites  ;  a  history 
of  a  sojourn  in  Australia  or  close  association  with  dogs  is 
suggestive.  The  characteristic  evidence  of  free  fluid  is 
not  present,  and  in  most  cases  the  effusion  may  be  con- 
nected directly  with  an  enlarged  liver.  The  fluid  from 
a  hydatid  cyst  is  clear,  free  from  albumin,  and  of  low 
specific  gravity  (1,010)  ;  it  may  contain  sugar  and  chlorides 
and  the  characteristic  booklets  should  be  demonstrable. 

A  blood  examination  shows  definite  eosinophilia. 
The  signs  of  loculated  ascites  are  variable  and  depend  very 
much  on  the  size  of  the  effusion.  There  is  usually  a  constant 
dull  area  somewhere  or  other,  most  often  in  the  lower  half  of 
the  abdomen  ;  frequently  a  thrill  may  be  present  over  the 
dull  patch.  The  size  and  shape  of  the  dull  area  does  not 
alter,  or  only  alters  very  slightly,  with  change  of  posture. 

A  single  loculus  such  as  described  above  is  very  rare,  and, 
if  an  ovarian  cyst  can  be  excluded,  is  nearly  always  due  to 
tuberculous  peritonitis,  signs  of  which  (such  as  rolls  of 
doughy  omentum)  may  be  found  as  well.  More  often 
loculated  ascites  is  formed  at  the  same  time  as  a  collection 
of  free  fluid,  and  the  loculation  is  only  suspected  when 
peracentesis  fails  to  empty  the  abdomen. 


DISEASES   OF   THE   ALIMENTARY   TRACT      373 

The  differential  diagnosis  of  the  cause  of  any  case  of 
ascites  involves  a  detailed  consideration  of  the  symptoms 
and  signs  of  the  list  of  diseases  on  p.  370,  but  maj^  be  dis- 
cussed briefly  here. 

Ascites  may  be  divided  into  two  groups,  depending  on 
whether  it  is  caused  mainly  through  obstruction  to  the 
portal  venous  system  or  mainly  through  some  peritoneal 
affection. 

The  first  group  (obstructive)  comprises  : — 

(i.)  Valvular  and  Musculw  Heart  Lesions.     These  give 

their  own  conclusive  signs,  and  ascites,  in  such  conditions, 

is  usually  part  of  a  general  anasarca.     Mitral  stenosis, 

however,    often    causes    ascites    without    subcutaneous 

oedema. 

(ii.)  Large    Pericardial    Effusions.     Acute    pericarditis, 

calcareous  pericarditis,  adherent  pericardium,  and  chronic 

mediastinitis  are  all  likely  to  be  associated  with  ascites 

from  embarrassment  of  the  heart's  action  either  toxic  or 

mechanical. 

The  signs   of   pericardial    or   mediastinal    disease    are 

generally  appaient    and  will   indicate    the   cause   of  the 

ascites. 

(iii.)   Thrombosis  of  the  Portal  Vein  {vide  also  p.  386) 

causes  ascites,  enlargement  of  the  spleen,  and  hsematemesis 

and  is  likely  to  be  mistaken  for  cirrhosis,  but  may  be 

suspected  if  the  above  signs  develop  suddenly  in  a  patient 

with    some    debilitating    disease    whicli    is    likely    to    be 

complicated  by  venous  thrombosis. 

(iv.)  Cirrhosis  of  the  Liver  (wc^ealsop.  392).    The  patient 

may  give  a  history  of  chronic  gastritis  and  may  show 

signs  of  chronic  alcoholism  {vide  p.  201). 

The  liver  may  be  increased  in  size,  and  the  surface  may 

feel  nodular  to  palpation.     The  age  is  suggestive  (30  to  50 

years). 

The  second  group  (principally  peritoneal)  comprises  : — 
(i.)  Penal  Disease.     This  may  be  diagnosed  by  urinary 

examination. 

(ii.)  Perihepatitis.    This  may  give  no  other  sign  than 

recurrent  ascites  ;  if  due  to  syphilis  (as  is  often  the  casej 

the  Wassermann  reaction  may  hel|i  tlio  diagnosis. 


^74  MEDICAL   DIAGNOSIS 

(iii.)  Tuberculous    Peritonitis    has    been    discussed    on 

p.  100. 

(iv.)  Peritoneal  New  Growth.     There  should  be  evidence 

of    some   primary   focus    (such    as    stomach    or    ovary). 

Cancerous  cachexia  is  not  long  delayed.    Intra-abdominal 

masses  may  be  palpable,  and  secondary  nodules  in  the 

skin  round  the  umbihcus  are  not  uncommon. 

(v.)  New  Growth  Obstructing  the  Portal    Vein  usually 

causes  jaundice   also  from  obstruction  of  the  bileduct, 

and  there  are  likely  to  be  further  signs  referable  to  the 

growth  itself,  such  as  pyloric  obstruction  or  pancreatic 

disturbance. 

When  paracentesis  becomes  necessary  information  may 
be  gained  from  the  fluid  withdrawn.  Ordinary  ascitic  fluid 
is  a  clear  straw-coloured  liquid  with  a  specific  gravity  of 
1,015  )  it  contains  albumin,  but  does  not  clot  spontaneously. 

The  fluids  removed  from  purely  passive  effusions  and  from 
renal  disease  or  cirrhosis  show  a  prepondera.nce  of  endothelial 
cells.  In  mahgnant  disease  the  fluid  may  be  blood-stained, 
it  contains  endothelial  cells,  lymphocytes  and  polymorpho- 
nuclear leucocytes,  while  occasionally  fragments  of  tumour 
may  be  demonstrated. 

Lymphocytic  effusions  are  most  likely  to  be  found  in 
cases  of  tuberculous  peritonitis. 

The  presence  of  cholesterin  crystals  indicates  cyst  forma- 
tion, probabty  ovarian,  possibly  pancreatic. 

The  presence  of  a  thick  mucinous  fluid  that  will  not  run 
even  through  a  big  cannula  is  pathognomonic  of  one  variety 
of  ovarian  cyst  (pseudo -mucinous). 

B.  Peritonitis,  (a)  Acute  General  Peritonitis.  Apart 
from  traumatic  causes,  acute  generalised  peritonitis  is 
usually  the  result  either  of  perforation  of  a  hollow  viscus 
or  of  acute  inflammatory  change  in  part  of  the  intestinal 
cavial  {e.g.,  the  appendix  or  a  strangulation)  without  neces- 
sarily perforation,  for  the  coats  of  the  intestine  may  be  so 
damaged  as  to  permit  the  passage  of  bacteria  from  the  lumen 
of  the  gut — a  condition  found  also  at  times  in  carcinoma. 
Other  causes  may  be  salpingitis  (much  more  often  this 
causes  inflammation  limited  to  the  pelvic  peritoneum), 
spread    through    the    diaphragm    of    septic    intra-thoracic 


DISEASES   OF   THE   ALIMENTARY   TRACT      375 

processes  {e.g.,  empyemaj,  and  rarely  as  a  metastatic  infec- 
tion in  pneumonia  or  septicaemia. 

A  subacute  generalised  peritonitis  may  be  found  in  the 
terminal  stages  of  any  prolonged  debilitating  condition, 
especially  Bright's  disease. 

The  diagnosis  of  generalised  peritonitis  depends  on  the 
following  signs  and  symptoms  : — 

(i.)  Abdominal  imiii  :  sudden  in  onset,  severe  in  degree, 
at  first  diffuse,  then  more  localised  to  the  umbilicus,  and 
later  still  sometimes  to  the  site  of  the  lesion,  in  inflamma- 
tory as  opposed  to  perforation  cases. 

(ii.)  Vomitiiig.  This  usually  occuis  at  the  outset,  but 
then  often  passes  off  until  the  inflammation  has  become 
very  extensive,  when  it  sets  in  again  and  persists  with 
hiccups  till  the  end  :  after  a  time  the  vomited  matter 
becomes  dark  brown  and  has  a  fsecal  odour  (stercoraceous 
vomit). 

(iii.)  Rigidity.  The  muscles  are  held  stiff  ;  this  occurs 
at  first  over  the  lesion,  but  as  the  inflammation  spreads 
so  does  the  rigidity. 

(iv.)  Immobility.  The  respiration  becomes  shallow 
and  of  the  thoracic  type,  the  abdomen  moving  httle  or 
not  at  all. 

(v.)  Attitude.  The  patient  hes  on  his  back  and  does  not 
wilhngly  move  at  all  ;  one  or  both  legs  may  be  drawn  up. 

(vi.)  Pulse.  The  pulse  becomes  small,  rapid  and  hard 
(wiry). 

(vii.)  Temperature.  In  perforation  of  stomach  or 
duodenum  the  temperature  at  first  is  often  subnormal  ; 
in  appendicitis  there  is  more  often  moderate  pyrexia. 

(viii.)  Distension.  Peritonitis  is  quickly  followed  by 
paralysis  of  the  gut  and  great  distension. 

(ix.)  Tenderness.  There  is  usually  well-marked  diffuse 
tenderness  all  over  the  inflamed  area. 

(x.)  Facies.  The  hippocratic  face  appears  early  and  is 
really  evidence  of  collapse  ;  it  includes  anxious  expression, 
sunk  eyes,  sharp  nose,  and  pinched  appearance  generally. 

(xi.)  Constipation.  This  is  the  rule,  but  it  is  by  no 
means  absolute  ;  pneumoccocal  peritonitis,  in  especial, 
is  quite  often  accompanied  by  diarrhoea. 


376  MEDICAL   DIAGNOSIS 

(xii.)  Blood  Examination.  A  leucocytosis  (polymor- 
phonuclear) up  to  about  18,000  is  usual. 

In  typical  cases  the  diagnosis  presents  little  difficulty, 
especially  as  there  will  often  be  a  history  pointing  to  some 
disease  of  which  peritonitis  is  a  recognised  complication. 
Many  cases,  however,  do  not  present  the  classical  features 
as  described  above.  Especially  true  is  this  of  perforated 
gastric  or  duodenal  ulcer.  These  catastrophes  are  often 
ushered  in  by  an  acute  and  sudden  epigastric  pain  which  is 
followed  by  the  phenomena  of  severe  shock  ;  definite  signs 
of  peritonitis  may  be  absent  for  some  hours.  The  pulse 
especially  is  sometimes  most  misleading  ;  more  than  once 
have  we  seen  a  perforated  gastric  ulcer  with  a  fairly  soft 
steady  pulse  of  between  80  and  90  per  minute. 

As  a  rule,  however,  the  actual  perforation  is  followed 
quickly  by  local  abdominal  signs  indicative  of  peritoneal 
involvement,  and  if  the  case  is  seen  in  this  stage  the  condition 
is  not  likely  to  be  overlooked.  After  a  few  hours,  however, 
there  is  a  period  of  reactionary  calm  in  which  all  the  symptoms 
and  signs  are  very  much  diminished  and  the  general  condi- 
tion seems  greatly  improved.  If  the  case  is  seen  for  the 
first  time  in  this  reactionary  stage,  or  quiescent  interval  as  it 
may  be  called,  the  diagnosis  becomes  very  difficult  and  will 
depend  on  the  history,  the  facies,  and  the  pulse,  aided,  of 
course,  by  abdominal  examination.  The  quiescent  interval 
does  not  last  very  many  hours,  and  at  the  end  of  it  the  symp- 
toms of  generalised  peritonitis  quickly  become  unmistak- 
able, but  from  all  points  of  view  it  is  undesirable  to  postpone 
the  correct  diagnosis  as  late  as  this.  This  quiescent  interval 
is  also  seen  (but  to  a  less  extent)  in  acute  obstruction. 

The  presence  of  free  gas  in  the  peritoneum  is  proof  positive 
of  a  perforated  viscus,  but  it  is  not  very  easy  to  establish. 

The  sign  always  dcsciibed  is  a  diminution  of  liver  dulness 
in  the  right  axillary  region.  This  sign  is  of  value  if  the 
liver  dulness  has  been  mapped  out  shortly  before  the 
perforation  (which  is  only  likely  to  be  done  in  enteric  fever), 
but  the  liver  dulness  varies  so  much  with  the  alterations 
in  distension  of  the  colon  that  practically  the  value  of  the 
sign  is  not  very  great. 

In  rupture  of  a  duodenal  ulcer  the  tendency  is  for  the 


DISEASES   OF   THE   ALIMENTARY   TRACT      377 

contents  of  the  intestine  to  flow  into  the  right  ihac  fossa 
and  into  the  right  loin,  so  that  for  a  time  at  least  the  peri- 
tonitis is  principally  right  sided. 

If  a  ruptured  duodenal  ulcer  remains  unseen  for  thirty-six 
hours  or  so,  the  appearance  may  exactly  simulate  a  perfora- 
tive appendicitis.  In  perforated  gastric  ulcer,  except 
when  the  ulcer  is  right  on  the  pylorus,  the  tendency  is 
more  for  the  gastric  contents  to  sweep  downwards  into 
Douglas'  pouch  and  the  signs  are  bilateral  from  the 
outset. 

Acute  generahsed  peritonitis  may  be  confused  with  the 
following  : — 

(i.)  Intestinal  Colic  (vide  p.  360). 

(ii.)  Acute  Obstruction.  Here  there  is  le.ss  rigidity  and 
tenderness,  more  absolute  constipation,  earlier  and/more 
persistent  vomiting,  and  no  pyrexia. 

(iii.)  Hysteria.     This  may  exactly  simulate  peritonitis, 
and  unfortunately  the  woman  who  is  affected  this  way 
not  infrequenth'  is  under  observation  for  gastric  or  abdo- 
minal symptoms.     The  most  valuable  differential  points 
in  these  very  difficult  cases  are  the  pulse,  which  is  usually 
quite  good  in  functional  cases,  the  absence  of  couslant 
diffu.se  tenderness  if  a  lengthyexamination  is  made,  and  tlie 
fact  that  the  hysterical  patient  does  not  di.splay  such  a 
disinchiuition  to  move  about  in  bed  as  does  one  suffering 
from  })eritonitis.     In  addition  there  may  be  obvious  signs 
of  hysteria  which  may  suggest  the  diagnosis. 
{b)  AfiCTTE  Localised   Peritonitis.     The  chief  medical 
iiiterest  in  localised  acute  peritonitis  lies  in  a  subphrenic 
abscess.     This  is  the  result  of  a  leaking  gastric  or  duodenal 
ulcer,  or  it   may  occur  .secondarily  to  disease   of   the  liver 
or    gall-bladder,    (jr    from    downward    extension    of    intra- 
1  lioracic  sup])uratioii. 

Other  forms  of  loeali.sed  aiiulc  peritonitis  are  ulcerating 
new  growth,  appendicitis,  and  perimetritis,  which  are  more 
appropriately  considered  in  text-books  on  surgery  or  diseases 
of  women  respectively. 

A  Subphrenic  Abscess  may  be  one  of  the  most  difficult 
diagnostic  problems  in  medicine. 

On  the  rijrht  side  disease  of  the  liver  or  appendix  or  a 


378  MEDICAL   DIAGNOSIS 

duodenal  ulcer  is  the  usual  cause,  on  the  left  side  a  gastric 
ulcer  is  more  common. 

When  due  to  a  perforated  viscus  there  is  usually  gas  as 
well  as  pus  in  the  abscess  cavity. 

The  general  symptoms  are  those  of  septic  absorption. 

The  local  signs  are  : — 

(i.)  Embarrassment     of     respiration    from      impaired 

mobihty   of   the   corresponding   half   of   the   diaphragm. 

This  is  best  shown  by  X-rays,  but  may  also  be  detected 

clinically  by  noting  the  absence  of  pull  on  the  costal 

margin  of  the  affected  side. 

(ii.)  Dulness  at  the  base  of  the  lungs,  though  if  there 

is  much  gas  the  signs  rather  suggest  localised  pyo-pneumo- 

thorax. 

(iii.)  On  the  right  side  the  liver  may  be  pushed  down, 
(iv.)  On  the  left  side  the  stomach  resonance  may  be 

impaired.     It    may,    however,   be   increased   if   there   is 

much  gas  in  the  abscess. 

(v.)  Diaphragmatic   pleurisy   may  be   diagnosed   from 

the  presence  of  friction  and  the  nature  of  the  pain. 

(vi.)  Rigidity  of  the  upper  rectus  on  the  affected  side 

is  fairly  common,  but  need  not  be  marked. 

On  the  whole  it  may  be  said  that  unless  there  is  a  history 
pointing  to  gastric  or  duodenal  ulcer,  to  liver  or  gall-bladder 
disease,  or  to  appendicitis  a  subphrenic  abscess  is  more  than 
likely  to  be  diagnosed  as  a  basal  empyema  or  pyo-pneumo- 
thorax. 

Indeed,  this  diagnosis  is  often  correct,  for  subphrenic 
abscesses  spread  upwards  through  the  diaphragm  and  involve 
the  pleura  and  bases  of  the  lungs  very  readily  indeed. 

(c)  Chronic  Peritonitis.  One  result  of  chronic  locahsed 
peritonitis  is  the  formation  of  bands  and  adhesions  {vide 
p.  357).  Chronic  generalised  peritonitis  has  been  considered 
under  the  heading  "  Ascites  '"  with  the  exception  of  the 
disease  known  as  chronic  polyorrhomenitis  or  chronic 
polyserositis,  a  condition  characterised  by  multiple  and 
recurrent  serous  effusions  into  pleurae,  pericardium,  and 
peritoneum. 

Sometimes  the  tubercle  bacillus  is  responsible  for  this 
disease  ;    in  other  cases  the  etiology  is  obscure. 


DISEASES   OF   THE    ALBIENTARY   TRACT      379 

Chronic  peritonitis  is  occasionally  dry  throughout,  and 
in  such  cases,  and  sometimes  in  the  early  stages  of  the  wet 
forms,  a  definite  friction  rub  can  be  heard  with  a  stethoscope, 
or  felt  manually  over  different  regions  of  the  abdomen, 
particularly  over  the  hver  or  spleen  when  perihepatitis  or 
perisplenitis  is  in  active  progress. 


PART   IV 

CHAPTER   I 

DISEASES    OF   THE   LIVER,   BILIARY   APPARATUS, 
AND   PANCREAS 

DISEASES  OF  THE  LIVER  AND  BILE  PASSAGES 
I.  GENERAL  CONSIDERATIONS 

The  right  lobe  of  the  hver,  which  comprises  four-fifths  of 
the  entire  organ,  occupies  the  right  hypochondrium  and  the 
upper  part  of  the  epigastrium  as  far  as  the  middle  line. 
The  smaller  left  lobe  is  continued  across  the  epigastrium 
and  gradually  tapers  off  in  the  left  hypochondrium,  above 
and  rather  anterior  to  the  stomach. 

The  functions  of  the  liver  are  numerous  and  variable 
and  of  such  vital  importance  that  life  ceases  in  a  few  minutes 
when  the  liver  is  extirpated.  The  vital  functions  are  not 
the  formation  and  excretion  of  bile,  since  life  may  continue 
for  an  indefinite  period  with  obstructioji  to  the  biliary 
outflow. 

The  chief  functions  of  the  liver  may  be  enumerated  as 
follows  : — 

(i.)  Carhohydrate  Metabolism.  The  sugar  which  is  brought 
to  the  liver  in  the  portal  vein  is  converted  into  glycogen  and 
stored  as  such  in  the  individual  liver  cells.  When  the  body 
tissues  require  heat  energy  some  of  this  glycogen  is  recon- 
verted into  sugar  and  discharged  as  such  into  the  circulation. 

(ii.)  Glycolytic  Functio?).  A  considerable  amount  of  heat 
is  furnished  by  the  power  of  the  liver  to  break  down  circu- 
lating sugar  into  CO2  and  water. 

(iii.)  Proteid  Metabolism.  Toxic  substances,  the  result 
of  proteid  katabolism,  are  brought  to  the  liver  in  the  portal 
vein.     Thev  arc  converted  by   the  liver  into  harmless  or 


DISEASED    OF   THE    LIVER  381 

even  beneficial  bodies,  which  are  either  used  by  the  tissues 
or  excreted  by  the  kidnej^s  in  the  form  of  urea. 

The  bile  acids  and  pigments  are  to  some  extent  by- 
products of  this  proteolytic  function. 

(iv.)  Fat  Metabolism.  The  liver  possesses  the  po%yer 
of  both  storing  and  splitting  up  fat. 

(v.)  The  Secr'^fiott  of  Bile.  In  part  the  outpouring  of 
bile  is  the  means  by  which  the  liver  removes  some  of  the 
waste  jDroducts  of  its  own  cellular  activity,  but  at  the  same 
time  the  bile  itself  exercises  several  distinctly  beneficial 
functions — it  neutraHses  the  acid  gastric  juice  and  so 
assists  intestinal  digestion,  it  promotes  the  absorption  of 
fats  by  its  effect  on  the  surface  tension,  it  has  a  definite 
though  slight  amylolytic  action  of  its  own,  it  pro- 
motes intestinal  peristalsis,  and  it  is  po.ssibly  a  mild 
antiseptic. 

In  health  the  liver  dulness  reaches  as  high  as  the  lower 
border  of  the  sixth  rib  in  the  right  mammary  line,  the  eighth 
rib  in  the  mid-axillary  line,  and  the  tenth  rib  in  ther  line 
of  the  scapular  angle.  To  the  left  of  the  sternum  the  liver 
dulness  is  indistinguishable  from  the  cardiac  dulness  with 
which  it  merges.  The  left  lobe  of  the  fiver  cannot  be  per- 
ceived clinically  unless  it  is  enlarged,  but  it  extends  nearly 
as  far  to  the  left  as  the  left  nipple  line. 

The  lower  border  of  the  liver  is  not  usually  palpable 
below  the  right  costal  margin,  but  in  the  mid-line  it  reaches 
downwards  for  about  3  inches  below  the  base  of  the  xiphi- 
sternum. 

In  infants  and  young  children  the  liver  is  relatively 
very  much  larger  than  in  adults. 

Various  deformities  of  the  liver  are  described,  such  as. 
tightlacer's  liver,  which  has  a  deep  transverse  furrow  ;    and 
extra  lobes,  of  which  the  most  common  is  a  tongue-like 
process  (Riedel's  lobe)  reaching  downwards  from  the  neigh- 
bourhood of  the  gall-bladder. 

The  liver  may  be  displaced  downwards  by  thoracic 
disease,  by  subphrenic  abscess,  or  in  general  visceroptosis  ; 
upwards  by  increase  in  intra-abdominal  tension,  or  its 
position  may  be  transposed  in  "  situs  inversus  "  or  trans- 
position of  viscera. 


382  ^TEDTCAL   DIAGNOSIS 

The  size  of  the  liver  varies  greatly  in  different  diseases, 
both  general  and  of  the  organ  itself. 

II.  JAUNDICE 

By  jaundice  is  meant  a  yellow  coloration  of  the  skin, 
mucous  membranes,  and  conjunctivae,  occurring  as  a  result 
of  the  deposition  of  bile  pigments  in  these  tissues. 

All  jaundice  is  the  result  of  obstruction  to  the  proper 
flow  of  bile,  but  this  obstruction  may  be  partial  or  complete, 
and  may  occur  in  the  hepatic  or  common  bile-ducts  or  in  the 
bile  capillaries  within  the  liver.  These  latter  cases  may  be 
styled  "  intra -hepatic,"'  and  include  the  majority  of  so-called 
'■'  toxic  '■  or  "  hsematogenous  "  cases  of  jaundice  in  contra- 
distinction to  the  more  obvious  "extra-hepatic "'  or  "obstruc- 
tive "  types.  One  reason  why  such  apparently  shght 
degrees  of  intra-hepatic  obstruction  may  cause  jaundice 
is  the  fact  that  normally  bile  is  secreted  at  very  low  tension, 
so  that  a  very  slight  alteration  of  pressure  is  sufficient 
to  permit  of  the  absorption  of  bile  pigments  into  the 
blood. 

In  the  toxic  group  are  included  the  jaundice  of  certain 
poisons,  such  as  phosphorus,  arsenic,  and  snake  venom  ; 
of  certain  specific  infections,  such  as  yellow  fever,  malaria, 
scarlet  fever,  or  typhus  ;  of  severe  toxaemias,  such  as  acute 
yellow  atrophy,  epidemic  jaundice,  Weil's  disease,  and 
pernicious  anaemia.  It  is  presumed  that  in  all  these  cases, 
except  perhaps  acute  yellow  atrophy,  in  which  the  pronounced 
destruction  of  liver  cells  may  be  sufficient  to  explain  the 
jaundice,  there  is  haemolysis  (destruction  of  red  cells), and 
that  the  waste  products  so  formed,  especially  haemoglobin, 
are  excreted  in  the  form  of  bile  pigments,  which  are  therefore 
present  in  the  bile  in  excess.  This  excess  of  bile  pigment 
causes  increased  viscosity  of  the  bile,  which  in  itself  is 
sufficient,  with  or  without  a  concomitant  angio-cholitis, 
to  alter  the  tension  in  the  bile -ducts  enough  to  permit  the 
absorption  of  bile  into  the  blood-stream. 

It  may  be  remarked  that  often  in  such  cases  the  faeces 
are  not  pale  and  the  urine  does  not  contain  bilirubin,  as  is 
the  case  in  the  more  straightforward  cases  of  jaundice.     At 


DISEASES   OF   THE   LTVER  383 

the  same  time  in  pernicious  anaemia  and  in  acholuric  family 
jaundice  the  urine  commonly  contains  urobilin  in  very  much 
larger  amount  than  is  present  in  health. 

It  is  then  apparent  that  jaundice  itself  is  only  a  symptom 
of  some  underlying  pathological  condition  ;  nevertheless 
it  is  convenient  to  discuss  briefly  certain  clinical  forms  of 
jaundice. 

(a)  Catarrhal  Jaundice.  This  is  usually  an  affection  of 
young  peojile,  though  no  age  is  immune.  The  symptoms 
are  commonly  those  of  an  ordinary  bilious  attack  (gastro- 
duodenitis),  and  it  has  been  suggested  that  the  duodenal 
catarrh  produces  enough  sticky  mucous  to  block  up  the 
opening  of  the  ampulla  of  Vater  and  so  obstruct  the  flow 
of  bile.  It  has  further  been  suggested  that  in  many  cases 
the  catarrhal  infection  spreads  through  the  bile  papiUa 
and  produces  a  similar  inflammation  in  the  common  bile- 
duct.  More  recently  the  view  has  been  advanced  that  the 
real  trouble  is  in  the  head  of  the  pancreas,  which  becomes 
swollen  from  catarrh  spreading  up  the  pancreatic  duct  from 
the  duodenum.  Since  in  60  per  cent,  of  all  cases  the  common 
bileduct  traverses  the  head  of  the  pancreas  it  is  reasonable 
to  suppose  that  swelling  of  the  pancreas  will  obstruct  this 
duct.  As  the  catarrh  sub.sides  so  does  the  jaundice 
abate. 

In  many  cases  the  jaundice  is  the  first  sign  ;  in  others  the 
jaundice  is  preceded  by  acute  gastritis  with  anorexia, 
furred  tongue  and  vomiting.  The  bowels  are  usually  con- 
fined. There  is  little  or  no  fever.  As  the  jaundice  deepens 
the  liver  often  becomes  enlarged  and  tender.  The  motions 
are  clay  coloured,  the  urine  is  dark  and  contains  bilirubin. 

The  gastric  symptoms  generally  subside  in  a  few  days, 
but  they  may  persist  for  much  longer  and  they  may  recur 
if  an  unsuitable  diet  is  permitted  or  if  the  patient  takes 
a  "chill." 

The  prognosis  is  uniformly  good,  though  a  chronic  catarrhal 
jaundice  may  persist,  in  rare  cases,  until  some  such  opera- 
tion as  chole -cyst -enterostomy  is  performed. 

It  is  important  to  remember  that  catarrhal  jaundice 
may  occur  in  the  cour.se  of  malignant  disease  of  the  liver  or 
pancreas  and  may  improve  with  suitable  treatment ;    a^ 


384  MEDICAL   DIAGNOSIS 

a  rule,  however,  in  malignant  cases  the  jaundice  gets  pro- 
gressively deeper  until  the  end. 

Jaundice  is  often  associated  with  itching  of  the  skin  and 
a  slow  pulse  ;  both  these  phenomena  are  more  marked  in 
the  malignant  cases  than  in  simple  catarrh. 

(6)  Epidemic  Catarrhal  Jaundice.  It  sometimes  happens 
that  catarrhal  jaundice  occurs  in  a  definitely  epidemic  form 
and  spreads  from  case  to  case  just  like  specific  infection. 
Even  in  apparently  sporadic  cases,  careful  inquiry  will 
often  reveal  other  cases  in  the  same  house  or  family  at  the 
same  time.  Nevertheless,  there  is  not  at  present  sufficient 
evidence  to  justify  the  opinion  that  catarrhal  jaundice  is 
a  specific  infection,  though  it  is  probable  that  occasionally 
it  may  be  so. 

(r)  Weil's  Disease.  A  form  of  infections  disease  in  which 
jaundice  is  a  prominent  symptom  ;  there  is  no  real  evidence 
that  there  is  any  specificity  of  infectious  agent,  though  the 
Bacillus  proteus  fluorescens  has  been  credited  with  being 
the  cause. 

It  is  possible  that  tainted  meat  may  be  responsible  for 
certain  outbreaks  of  this  disease,  and  in  one  series  of  thirteen 
cases  no  fewer  than  nine  of  the  patients  were  employed  in 
a  slaughterhouse. 

The  onset  is  sudden,  often  with  a  rigor,  the  temperature 
rises  quickly  to  104°,  and  there  are  pains  all  over,  but 
especially  in  the  calves  of  the  legs. 

The  jaundice  develops  on  the  second  or  third  day  and  the 
liver  becomes  swollen  and  tender. 

The  spleen  is  always  enlarged,  and  there  is  a  coincident 
nephritis. 

Insomnia  and  delirium  are  conunon  during  the  height 
of  the  disease,  but  the  prognosis  is  fairly  good, 
since  most  cases  are  convalescent  by  the  end  of  a 
fortnight,  though  there  is  always  a  tendency  to  relapse. 
The  disease  may  be  mistaken  for  relapsing  fever  or  for 
a  mild  case  of  yellow  fever  :  in  the  former  case  the 
characteristic  spirillum  can  be  detected  in  the  blood  ;  in 
the  latter  the  locality  in  which  the  disease  occurs  is  an 
important  point. 

(d)  Icterus    Neonatorum.      The    majority    of   all    infants 


DLSEAfSES    OF   THE    Li\'Ell  385 

show  a  mild  jaundice  soon  afterbirth  whieh  passes  away  com- 
pletely in  a  few  days. 

This  form  of  jaundice  is  attended  by  no  unpleasant 
symptoms  and  must  be  regarded  as  physiological. 

Possibly  it  may  be  due  to  the  destruction  during  the  first 
week  of  extra -uterine  life  of  the  excess  of  red  blood  cells 
which  is  present  in  the  newly  born. 

(e)  Infective  Jaundice  in  the  newly  born.  This  may 
result  from  a  bacterial  infection  via  the  umbilical  vein 
and  may  be  regarded  as  an  acute  infective  hepatitis,  which, 
however,  is  usually  but  one  manifestation  of  a  true  septi- 
caemia. 

Infective  jaundice  of  infants  may,  however,  originate  in 
the  intestine,  and  is  then  said  to  be  due  to  the  Bacillus  coli 
or  Bacillus  lacticus. 

The  clinical  features  are  cyanosis,  jaundice,  and  diarrhoea. 

The  mortality  is  high,  and  the  duration  of  the  disease 
about  ten  days. 

This  variety  of  jaundice  is  probably  extremely  infectious, 
and  the  stools  should  be  as  strictly  treated  as  in  a  case  of 
enteric  fever. 

III.  ACUTE  YELLOW  ATROPHY  OF  THE  LIVER 

(^Icterus  Gravis). 

This  is  an  extremely  rare  condition  and  is  manifested  by  a 
profound  toxaemia  which  affects  principally  the  liver.  The 
result  is  an  extensive  degeneration  of  the  hepatic  cells,  severe 
and  progressive  delirium,  coma  and  death. 

The  similarity  of  the  chnical  appearances  in  cases  of 
phosphorus  poisoning  is  too  striking  to  be  overlooked, 
but  there  are  definite  differences,  and  the  only  justifiable 
deduction  is  that  the  toxins  of  acute  yellow  atrophy  act  on 
Ihc  human  organisms  in  a  somewhat  similar  manner  to 
i)hosphorus. 

It  may  be  mentioned  here  that  in  phosphorus  poisoning 
the  liver  is  increased  in  size  and  contains  ten  times  the 
normal  percentage  of  fat,  while  in  acute  yellow  atrophy 
the  liver  is  small  and  shrunk  and  contains  the  normal 
])ro})ortion  of  fat. 

Acute  yellow  atrophy  is  twice  as  common   in  women   as 

M.D.  25 


386  MEDICAL  DIAGNOSIS 

in  men,  and  is  noticeably  most  often  seen  in  combination 
with  pregnancy. 

The  age  incidence  is  20  to  40  years,  but  cases  have 
developed  in  childhood. 

The  symptoms  are  at  first  those  of  catarrhal  jaundice, 
but  after  five  or  six  days  obstinate  vomiting  sets  in  and  the 
jaundice  assumes  a  greenish  tint.  Hsematemesis  is  frequent, 
blood  is  often  passed  in  the  motions  and  other  haemor- 
rhages are  common.  Within  the  next  twenty-four  hours 
the  patient  becomes  delirious  and  then  semi-conscious  ; 
leucine  and  tyrosine  are  found  in  the  urine,  the  pulse  becomes 
very  rapid  and  feeble,  and  death  takes  place  in  two  or  three 
days. 

The  diagnosis  must  be  made  from  Phosphorus  Poisoning 
nnd  Portal  PycBmia. 

In  Phosphorus  Poisoning  it  should  be  possible  to  get  a 
history  of  exposure  to  this  poison  or  of  its  accidental  or 
intentional  ingestion  ;  the  earliest  symptom  is  vomiting, 
and  there  is  usually  a  quiescent  interval  between  the  vomit- 
ing stage  and  the  graver  toxic  stage.  Phosphorus  can  be 
detected  in  the  vomit  and  the  liver  dulness  is  increased. 

In  Portal  Pycemia  there  is  a  history  of  some  septic  process 
in  the  portal  area  such  as  appendicitis  ;  the  jaundice  is  less 
deep  and  rigors  are  a  feature  of  the  case. 

IV.  PYLEPHLEBITIS. 

Inflammatory  changes  in  the  wall  of  the  portal  vein  may 
result  either  in  thrombosis  or  in  suppuration. 

(i.)  Adhesive  Pylephlebitis  (pylethrombosis).  This  may 
occur  in  any  of  the  conditions  which  favour  venous  throm- 
bosis elsewhere,  and  it  is  probable  that  both  bacteria  and  a 
damaged  condition  of  the  vessel  wall  are  necessary  for  its 
production.  The  condition  is  rare  and  usually  fatal  in  a 
short  time. 

The  diagnosis  of  portal  thrombosis  can  scarcely  ever  be 
made,  since  the  cardinal  symptoms  of  ascites,  enlargement 
of  the  spleen  and  hsematemesis,  are  so  commonly  present 
in  uncomplicated  portal  cirrhosis. 

Sudden  abdominal  pain  with  the  passage  of  blood  by  the 


DISEASES   OF   THE   LIVER  387 

bowel,  followed  shortty  by  ascites  and  an  enlarged  spleen, 
may  suggest  the  possibility  of  pylethrombosis. 

(ii.)  Suppurative  Pylephlebitis.  This  is  the  result  of  a 
more  severe  infection  than  the  preceding,  with  the  conse- 
quence that  multiple  abscesses  are  formed  in  the  liver 
substance  round  the  branches  of  the  portal  vein.  The  portal 
vein  itself  is  generally  filled  with  purulent  bloodstained 
matter,  but  this  is  not  always  the*  case,  since  the  smaU 
abscesses  may  be  formed  by  infective  emboli  direct  from 
the  primary  site  of  infection. 

Appendicitis  is  responsible  for  40  per  cent,  of  aU  cases, 
but  ulceration  anywhere  in  the  area  drained  by  the  portal 
system  may  be  the  cause. 

Recovery  has  occurred  in  a  small  number  of  cases,  but 
death  usually  takes  place  in  a  few  weeks. 

The  symptoms  are  a  high  temperature  of  septic  type, 
rigors  and  profuse  perspirations,  with  the  addition  of  ab- 
dominal pain,  vomiting  and  distension,  enlargement  of  the 
liver  and  usually  of  the  spleen,  and  very  often  a  shght 
amount  of  jaundice. 

The  diagnosis  is  only  likely  to  be  made  when  the  above 
symptoms  develop  during  the  course  of  some  such  con- 
dition as  ulcerative  appendicitis  or  some  septic  rectal 
disease. 

Suppurative  Pylephlebitis  must  be  distinguished  from — ■ 
{a)  Suppurative   Cholangitis.     The    general    symptoms 

are  similar,   but   the  jaundice  is  more   marked  and  the 

spleen  does  not  enlarge. 

{b)  Tropical  Abscess.     The  symptoms  are  less  severe  ; 

there  is  no  splenic  enlargement,  but  there  is  generally  a 

much  more  localised  swelling  of  the  liver,  and  there  is 

always  a  history  of  amcebic  dysentery. 

(c)  Subphrenic  Abscess.      The  symptoms  may  be  very 

similar,  but  the  diaplu-agm  is    much  more  immobilised 

and  at  a  higher  level,  rigors   are   not   so   constant   and 

jaundice  is  the  exception  ;  further,  a  history  pointing  to 

previous  gastric  or  duodenal  ulcer  would  be  strongly  in 

favour  of  subphrenic  abscess. 


25—2 


388  MEDICAL   DIAGNOSIS 

V.  SINGLE  LIVER  ABSCESS  (Tropical  Abscess). 

This  condition  is  only  met  with  as  a  sequel  to  amoebic 
dysentery  ;  a  fact  of  primary  importance  in  its  differential 
diagnosis. 

The  abscess  is  usually  situated  in  the  right  lobe  of  the  liver. 
The  symptoms  are  a  dull  pain  in  the  liver  region,  which 
becomes  acute  as  the  abscess  nears  the  surface,  an  irregular 
temperature,  and  the  general  phenomena  of  septic  absorption. 
The  signs  are  variable — the  most  constant  is  an  increase 
in  the  size  of  the  liver  ;  there  may  be  a  localised  swelling, 
but  this  depends  on  the  situation  of  the  abscess. 

Jaundice  is  an  important  point,  but  is  often  absent. 
Peritoneal  friction  may  be  audible  if  the  inflammatory 
process  reaches  the  surface. 

Impairment  of  the  movement  of  the  corresponding  half 
of  the  diaphragm  can  be  demonstrated  by  the  X-rays,  and 
there  is  usually  evidence  of  collapse  of  the  base  of  the  lung 
on  the  affected  side.  For  this  reason  empyema  is  often 
suspected,  and  indeed  is  often  present,  since  the  liver  abscess 
commonly  ruptures  into  the  pleura  or  lung. 
There  is  usually  a  high  leucocytosis. 

A  Hydatid  Cyst  of  the  liver  may  give  rise  to  the  same 
physical  signs  as  a  single  abscess,  and  a  suppurating  hydatid 
cyst  causes  the  same  symptoms  also. 

As  a  general  rule  it  may  be  said  that  a  localised  cystic 
swelling  is  strongly  in  favour  of  hydatid  disease,  especially 
if  a  thrill  can  be  elicited  on  careful  palpation.  In  hydatid 
disease  there  is  nearly  always  a  definite  eosinophilia. 

Liver  abscess  may  be  indistinguishable  from  subphrenic 
abscess,  and  only  most  careful  inquiry  into  the  previous 
history  of  the  patient  as  regards  amoebic  dysentery  or 
gastric  or  duodenal  ulcer  will  lead  to  a  correct  diagnosis. 

VI.  MULTIPLE  LIVER  ABSCESS  {ridr  "  Suppurative 

Pylephlebitis  "). 

VII.   CONGESTION  OF  THE  LIVER. 

(i.)  Passive  Congestion.  The  so-called  nutmeg  liver  results 
from  imperfect  function  of  the  right  heart,  whether  due 
pri]najily  to  pulmonary  or  cardiac  disease. 


DISEASES    OF   THE   LIVER  389 

The  flow  of  blood  through  the  hepatic  veins  is  impeded  ; 
the  blood  is  dammed  up  in  the  liver  and  secondarily  in  the 
entire  portal  system. 

The  liver  becomes  enlarged  and  tender  ;  it  may  pulsate  ; 
and  ascites  is  common. 

The  symptoms  are  cliiefly  gastro-intestinal  and  can  be 
attributed  to  the  catarrh  set  up  in  the  ahmentary  tract  by  the 
portal  congestion. 

The  liver  is  disturbed  in  its  functions,  and  the  shght 
jaundice  so  often  seen  in  the  later  stages  of  cardiac  disease 
may  be  attributed  to  this  cause. 

The  diagnosis  of  a  nutmeg  liver  is  not  required  separately  ; 
the  condition  can  be  inferred  when  the  diagnosis  of  chronic 
right  heart  disability  has  been  made. 

(ii.)  Active  Congestion.  This  is  undoubtedly  produced 
by  certain  infective  agents,  especially  certain  tropical 
diseases,  such  as  malaria  and  dj'senterj-,  and  it  is  seen  most 
typically  in  those  who  have  lived  for  many  years  in  the 
East.  "^    "         ' 

At  the  same  time  any  dietetic  errors  which  induce  chronic 
gastro-intestinal  catarrh,  especially  alcohohsm,  permit  the 
formation  of  abnormal  or  excessive  metabolic  products, 
which  in  their  turn  result  in  an  added  flow  of  portal  blood 
to  the  liver. 

The  symptoms  of  active  congestion  of  the  liver  fall 
into  two  groups — first,  those  of  gastro-intestinal  catarrh ; 
and,  secondly,  those  referable  more  directly  to  the 
liver  itself — namely,  pain,  tenderness,  and  enlargement  of 
the  organ,  slight  jaundice,  headaches,  giddiness,  bad  temper, 
and  mental  depression. 

In  the  tropics  the  above  picture  is  met  with  in  a  very 
intense  form  with  the  addition  of  moderate  pyrexia,  and 
it  is  then  justifiable  to  consider  the  condition  to  be  one  of 
acute  hepatitis. 


VIII.   CIRRHOSIS   OF  THE   LIVER. 

The    following  varieties  of  cirrhosis  will   be  considered  ; 
the  classification  is  not  altogether  satisfactory,  but    in  the 


390  MEDICAL  DIAGNOSIS 

present  state  of  our  knowledge    it  is  best  to  consider  the 
subject  from  the  standpoint  of  morbid  anatomy  : — 

(i.)  Multilobular  Cirrhosis  (atrophic,  portal,  Laennec's 

cirrhosis,  hob-nailed  liver). 

(ii.)  Unilobular  Cirrhosis  (hypertrophic,  biliary,  Hanot's 

cirrhosis). 

(iii.)  Obstructive  biliary  cirrhosis. 

(iv.)  Pericellular    Cirrhosis    (congenital    syphilitic    cir- 
rhosis). 

(i.)  Multilobular  or  Portal  Cirrhosis.  This  disease 
affects  men  much  more  commonly  than  women,  and  is 
most  often  seen  between  the  ages  of  30  and  50.  Children 
are  sometimes  affected. 

There  can  be  no  doubt  that  portal  cirrhosis  results  from 
the  action  of  poisons  conveyed  to  the  hver  by  the  portal 
vein.  The  nature  of  these  poisons  is  quite  unknown,  but 
it  is  reasonable  to  suppose  that  they  are  elaborated  in  the 
stomach  or  intestines,  and  that  their  formation  is  favoured 
by  certain  articles  of  diet  whch  are  unsuitable  to  the  parti- 
cular individual .  Such  evidence  as  there  is  favours  somewhat 
the  idea  that  the  toxins  are  the  result  of  bacterial  action 
rather  than  of  plain  katabolism,  and  that  the  particular 
foodstuffs  act  by  producing  a  type  of  gastro-intestinal 
catarrh  which  permits  the  growth  of  a  group  of  organisms. 
These  manufacture  the  particular  toxins  which  have  such 
a  disastrous  effect  on  the  liver. 

With  the  exception  of  alcohol,  no  special  foodstuffs  can 
be  mentioned  which,  for  certain,  are  capable  of  causing 
cirrhosis.  The  action  of  alcohol  is  unproven  ;  it  has  been 
suggested  that  it  may  act  by  inhibiting  that  function  of  the 
liver  which  detoxicates  the  products  of  bacterial  activity. 
Certain  it  is  that  alcohol  may  produce  cirrhosis,  but  it  is 
equally  certain  that  it  need  not  do  so,  and  that  cirrhosis 
quite  often  occurs  in  teetotallers. 

Morbid  Anatomy.  The  essential  change  consists  in  the 
formation  of  fibrous  tissue  round  the  ramifications  of  the 
portal  vein  in  the  liver  substance  ;  hence  the  fibrous  strands 
tend  to  include  several  lobules  at  a  time.  The  contraction 
of  the  fibrous  tissue  squeezes  out  the  liver  substance 
on    the    surface    of    the    organ  in    the    form    of    rounded 


DISEASES   OF   THE   LIVER  391 

nodules    (hofc -nails)  and    may    result    in    considerable   dis- 
tortion. 

The  liver  itself  may  be  enlarged  or  shrunken  at  the  time 
of  death  ;  it  is  probable  that  it  is  large  at  first  and  tends  to 
shrink  if  the  patient  survives  long  enough. 

The  interference  with  the  blood  flow  through  the  liver 
causes  dilatation  of  the  portal  vein,  and  the  stagnation  of 
the  blood-stream  may  result  in  portal  thrombosis. 

In  old  standing  cases  there  is  often  considerable  fatty 
change  in  the  liver  cells. 

Diagnosis.  The  symptoms  and  signs  of  portal  cirrhosis 
fall  naturally  into  two  gi'oups— first,  the  symptoms  which 
depend  on  the  primarj^  gastro-intestinal  catarrh,  and, 
secondly,  those  which  are  referable  to  the  liver  itself.  The 
second  group  are  often  absent  for  a  considerable  time,  and 
when  they  have  developed  the  diagnosis  is  not  difficult  :  at 
the  same  time  the  prognosis  is  very  bad,  and  death  can 
generally  be  anticipated  in  a  few  months. 

On  the  other  hand,  the  signs  of  gastro-intestinal  patarrh 
do  not  necessarily  indicate  cirrhosis  of  the  liver,  so  that  in 
its  early  stages  the  diagnosis  is  extremely  difficult  if  not 
impossible.  An  early  stage  of  cirrhosis  may  be  su.spected 
in  a  man  of  from  30  to  50  years  who  has  the  aspect  and  history 
of  alcoholic  excess,  and  who  complains  of  dyspepsia,  morning 
sickness,  lack  of  appetite  (especially  for  breakfast),  and 
looseness  of  the  bowels.  The  tongue  is  furred,  there  is  a 
yellowish  tint  to  the  sclerotics,  and  often  there  is  a  slight 
oedema  of  the  shins. 

It  is  obvious  that  the  above  phenomena  must  be  persistent 
in  order  to  justify  a  diagnosis  of  cirrhosis,  a  diagnosis  which 
is  supported  if  a  large  liver  can  be  demonstrated. 

As  the  disease  progresses  signs  more  directly  referable 
to  portal  obstruction  and  to  the  liver  become  manifest ; 
these  include  : — 

(a)  Evidence  of   attempted   anastomosis  between  the 

portal  and  systemic  circulation,   as  shown  by  enlarged 

veins  around  the  umbilicus  and  by  oesophageal  and  rectal 

piles,  which   may  burst  and  give  rise   to   hfematemesis 

and  melajna. 

{b)  Ascites,    which    cannot   be     considered    as    purely 


392  MEDICAL   DIAGNOSIS 

mechanical,    as    it    possibly    depends    in  part  on  a  low 

grade  of  peritonitis  and  in  part  on  an  increased  toxicity 

of  the  blood  which  damages  the  capillary  walls. 

(c)  Jaundice.      This  is  rarely  present  to  any  extent ; 

at  the  same  time  a  sallow,  yellowish  complexion  is  the 

rule  and  depends  on  the  toxaemia  and  malnutrition. 
{d)  Liver.      The    liver  itself  may  be  large  or  small  : 

a  large,  nobbly  liver  is  a  great  help  in  diagnosis  ;    the 

presence   of    a   small   liver   can  rarely  be   proved  with 

certaint3^ 

Course.  When  once  ascites  has  developed  the  expectation 
of  life  is  not  much  more  than  a  year,  and  when  once  the  ascites 
has  become  so  marked  as  to  require  tapping  the  expectation 
of  life  is  less  than  six  months. 

At  the  same  time  cases  occur  from  time  to  time  in  which 
cirrhosis  of  the  liver  is  present  and  which  are  tapped  as 
many  as  fifty  or  sixty  times  without  appearing  much  the 
worse  for  it.  It  is  possible  that  in  such  cases  the  cirrhosis  is 
at  a  much  earlier  stage  than  usually  causes  ascites,  and 
that  the  ascites  depends  mainly  on  some  other  factor, 
such  as  chronic  peritonitis,  which  is  often  of  syphilitic 
origin. 

Differential  Diagnosis.  This  depends  rather  on  exclud- 
ing other  possible  causes  for  any  prominent  symptom. 
For  example,  hsematemesis  requires  the  exclusion  of  gastric 
ulcer  and  also  of  gastric  carcinoma.  A  test  meal  {vide 
p.  327)  maybe  of  value  in  this  respect  ;  while  a  blood  count 
would  exclude  hoematemesis  from  splenic  anaemia,  leukaemia, 
or  pernicious  anaemia. 

The  differential  diagnosis  of  ascites  has  been  dealt  with 
{vide  p.  373). 

In  children  cirrhosis  of  the  liver  is  at  first  usually  mistaken 
for  tuberculous  peritonitis.  If  paracentesis  is  performed  an 
excess  of  endothelial  cells  indicates  cirrhosis,  while  in 
tuberculosis  the  effusion  is  lymphocytic. 

(ii.)  Biliary  Cirrhosis  of  Hanot  (Unilobular 
Cirrhosis).  This  disease  is  rarely  or  never  met  with  in 
England.  It  is  true  that  the  fibrous  tissue  not  infrequently 
assumes  a  unilobular  distribution  in  certain  parts  of  the 
liver  (especially  under  the  capsule)  of  very  advanced  cases  of 


DISEASES   OF   THE   LIVER  393 

portal  cirrhosis,  but  there  is  no  reason  for  supposing  that 
primarily  they  are  anything  but  portal  cirrhosis. 

True  biliary  cirrhosis  is  supposed  to  be  due  to  toxins 
which  are  absorbed  into  the  blood  and  which,  in  process  of 
excretion  into  the  bile,  excite  a  descending  cholangitis. 
The  absence  of  duodenal  catarrh,  as  well  as  the  fact  that  the 
spleenis  often  enlarged  before  there  is  evidence  of  cholangitis, 
seems  to  be  much  against  the  suggestion  that  the  condition 
is  an  ascending  inflammation  of  the  bileducts. 

The  fibrosis  occurs  round  the  bile  channels,  and  so  includes 
but  one  lobule  of  liver  substance  at  a  time. 

It  is  worthy  of  notice  that  in  all  probabihty  certain  cases 
of  biliary  cirrhosis  are  comphcated  in  their  later  stages  by 
superadded  portal  cirrhosis.  In  such  cases  the  primary 
lesion  may  well  be  overlooked  unless  the  patients  have 
been  under  observation  for  a  long  period. 

Biliary  cirrhosis  affects  men  much  more  frequently  than 
women  ;  the  usual  age  is  20  to  35  years,  but  children  are 
by  no  means  immune.  The  disease  is  probably  always 
fatal,  but  it  runs  a  course  of  several  years — ten  or  twelve 
years  is  not  at  all  unusual. 

The  clinical  features  are  as  follows  : — 

{a)  Jaundice.     This  is  usually  definite,  but  not  very 

deep  ;    it  may  vary  in  intensity,  but  never  disappears. 

There  is  bile  in  the  urine,  but  the  motions  are  not  clay 

coloured. 

(6)  Enlarged   Spleen.     This  may  be  the  earliest  sign  ; 

the  spleen  may  become  very  large,  and  usually  shows 

more  or  less  perisplenitis. 

(c)  Enlarged  Liver.  The  liver  becomes  very  large  ; 
it  remains  smooth  and  firm,  and  is  often  quite  tender 
throughout  the  ilhiess. 

[d)  Abdominal  Pain.  The  large  liver  may  cause  a 
dull  dragging  pain,  but,  quite  apart  from  this,  there  is 
a  liability  to  paroxysms  of  severe  abdominal  pain, 
which  are  accompanied  by  deepening  jaundice  and  an 
increase  in  the  size  of  both  liver  and  spleen.  They  do 
not  last  long,  but  recur  with  increasing  frequency. 
Biliary  cirrhosis  must  be  distinguished  from  : — 

(1)  Portal    Cirrhosis.     In    tliis    jaundice    is    rare    and 


394  MEDICAL   DIAGNOSIS 

ascites  is  common  ;   the  patient  is  older  and  the  duration 
of  the  established  disease  is  much  shorter. 

(2)  Malignant  Disease.  The  age  of  the  patient,  the 
shape  of  the  liver,  the  evidence  of  malignant  disease  else- 
where, the  frequency  of  an  obstructive  type  of  jaundice, 
and  the  very  short  course  of  the  case  should  not  present 
much  difficulty. 

(3)  Gall- Stones.  The  liver  is  not  usually  much  enlarged, 
the  spleen  is  rarely  enlarged  at  all  ;  the  jaundice  is  much 
deeper,  and  the  stools  are,  for  a  time  at  least,  clay  coloured. 

(4)  Syphilis  of  the  Liver.  The  liver  is  not  often  uniformly 
enlarged  ;  the  spleen  need  not  be  enlarged  at  all,  and  there 
should  be  other  evidence  of  syphilis.  A  Wassermann 
reaction  must  be  performed. 

(iii.)  Obstructive  Biliary  CiREHOSis.  In  certain  cases  of 
biliary  obstruction  a  unilobular  type  of  cirrhosis  may  develop 
as  a  secondary  condition. 

The  symptoms  are  those  of  primary  biliary  obstruction. 

(iv.)  Pericellular  Cirrhosis.  One  manifestation  of  con- 
genital syphilis  may  be  an  acute  diffuse  hepatitis.  If  the 
infant  survives  long  enough  a  diffuse  intra -lobular  or  peri- 
cellular fibrosis  results. 

The  diagnosis  may  be  made  from  the  discovery  of  a  large, 
hard,  smooth  liver,  with,  or  more  rarely  without,  other 
manifestations  of  congenital  syphilis.  Jaundice  may  develop 
and  is  an  unfavourable  sign. 

IX.    NEW  GROWTHS  OF  THE  LIVER. 

Innocent  neoplasms  of  the  liver  are  not  of  clinical 
significance. 

Angeiomas  are  frequently  found  post  mortem. 

Malignant  disease  of  the  liver  maybe  primary  or  secondary ; 
in  either  case  the  growth  may  be  a  sarcoma  or  a  carcinoma. 

Secondary  growths  in  the  liver  are  very  common,  and 
carcinoma  is  much  more  often  seen  than  sarcoma. 

Primary  growths  in  the  liver  are  very  rare,  but  when 
present  are  nearly  always  carcinomatous.  The  growths  are 
usually  secondary  to  a  primary  focus  in  the  portal  area, 
especially  the  stomach  and  head  of  the  pancreas. 


DISEASES   OF   THE   LIVER  395 

The  symptoms  are,  first,  those  common  to  malignant 
disease  elsewhere  (and  here  it  may  be  stated  that  a  large 
number  of  patients  die  of  carcinoma  elsewhere  and  have, 
post  mortem,  secondary  deposits  in  the  liver,  and  yet  during 
life  there  was  no  reason  to  suspect  that  the  liver  was  involved) ; 
and,  secondly,  symptoms  more  directly  referable  to  the 
liver,  such  as  an  obstructive  type  of  jaundice  and  a  large, 
nobbly  or  irregular  liver. 

Ascites  is  not  infrequent,  but  it  is  not  so  common  as 
jaundice. 

In  maUgnant  disease  of  the  liver  the  jaundice  often  depends 
on  the  presence  of  a  malignant  gland  in  the  portal  fissure, 
or  carcinoma  of  the  head  of  the  pancreas.  The  jaundice 
deepens  steadily  to  a  deep  olive-green  colour,  hardly  ever 
remits,  and  is  often  accompanied  by  severe  itching  of  the 
skin  and  by  a  very  slow  pulse. 

The  urine  contains  bile,  and  the  motions  are  pale,  greasy, 
and  very  offensive. 

Other  signs  which  may  occur  are  secondary  nodules 
of  growth  at  the  umbilicus,  audible  friction  from  peri- 
hepatitis when  a  nodule  reaches  the  surface  of  the  liver,  and 
an  irregular  pyrexia. 

Diagnosis.  Great  importance  has  been  laid  on  the  occur- 
rence of  manifest  enlargement  of  the  gall-bladder,  since  it 
is  said  that  this  does  not  occur  with  jaundice  unless  the 
cause  is  malignant  disease. 

Though  there  are  many  causes  of  enlarged  hver,  these 
usually  present  certain  characteristic  clinical,  features,  and 
do  not  enter  into  the  practical  diagnosis  of  malignant 
disease  of  the  liver. 

Great  difficulty  may,  however,  arise,  when  there  is 
a  large  liver  and  no  discoverable  primary  lesion,  in  dis- 
tinguishing between  malignant  disease,  cirrhosis,  and 
syphilis. 

ft!  addition  to  the  history  and  aspect  of  the  patient 
the  following  may  assist : — 

If  the  liver  can  be  felt  the  size  of  the  nodules  is  important, 
since  the  cirrhotifr  nodules  are  always  small. 

The  occurrence  of  jaundice  is  somewhat  in  favour  ot 
malignant  disease,  but  the  character  of  the  jaundice,  with 


396  MEDICAL   DIAGNOSIS 

enlarged  gall-bladder  and  clay-coloured  stools,  as  described 
above,  is  very  important  evidence. 

Enlargement  of  the  spleen  is  distinctly  in  favour  of 
cirrhosis. 

An  umbilical  nodule  or  a  gland  above  the  clavicle  may  be 
considered  proof  positive  of  malignant  disease. 

The  cicatrisation  of  gummata  in  the  liver  may  produce 
deformities  closely  resembling  malignant  disease.  Syphilis 
however,  is  not  often  accompanied  by  jaundice,  neither  is 
ascites  a  likely  occurrence. 

In  any  case  of  doubt  a  Wassermann  reaction  should  be 
performed,  and,  although  a  person  with  malignant  disease 
of  the  liver  may  well  have  syphilis  also  and  so  give  a  positive 
reaction,  the  result  of  treatment  by  mercury  and  potassium 
iodide  will  soon  settle  the  question. 


X.    GALL-STONES. 

Women  are  much  more  prone  to  gall-stones  than  men ; 
they  usually  develop  in  the  second  half  of  life,  but  no  age 
is  immune. 

The  formation  of  these  calculi  is  influenced  to  some  extent 
by  diet,  since  they  are  relatively  infrequent  in  people  who 
eat  a  great  deal  of  meat. 

The  common  basis  for  gall-stones  is  cholesterin  ;  occasion- 
ally pure  pigment  calculi  are  met  with.  Cholesterin  is 
secreted  by  all  mucous  surfaces  and  therefore  by  the  gall- 
bladder, so  that  stagnation  of  bile  predisposes  to  an  excess 
of  cholesterin  in  the  gall-bladder.  This  excess  of  cholesterin 
may  be  precipitated  by  any  factor  tending  to  produce  a 
deficiency  in  bile-salts,  which  normally  help  to  keep  it  in 
solution. 

In  addition  to  stagnation  of  bile,  some  inflammatory 
change  in  the  epithelium  of  the  gall-bladder  is  probably 
necessary  for  the  formation  of  calculi  ;  catarrhal  inflam- 
mation may  be  sufficient,  but  in  most  cases,  possibly  in  all, 
there  is  abacterial  element  at  the  bottom  of  the  inflammatory 
process.  The  Bacillus  coli,  Bacillus  typhosus,  staphylo- 
and  strepto-  cocci  have  been  shown  to  be  capable  of  pro- 


DISEASES   OF  THE   LIVER  307 

ducing    calculi,    and   Robsoii   believes    that   the   influenza 
bacillus  may  have  a  similar  power. 

The  calculi  vary  in  size  from  sand-like  particles  to  masses 
the  size  of  a  hen's  egg  or  larger  ;  they  are  soft  and  light, 
and  when  multiple  show  facets  from  friction  against  each 
other. 

Symptoms.  The  calcuU  may  remain  in  the  gall-bladder 
for  years  without  ever  giving  rise  to  symptoms  ;  in  such 
cases  a  tumour  is  rare,  since  the  gall-bladder  tends  to 
contract. 

On  the  other  hand,  even  though  the  calculi  remain 
in  situ,  urgent  symptoms  may  develop  as  the  result  of  chole- 
cystitis, which  is,  of  course,  more  prone  to  occur  when 
gall-stones  are  present. 

If  the  calculi  are  expelled  from  the  gall-bladder,  bihary 
colic  is  usually  very  obvious  while  they  are  passing  down  the 
cystic  duct  and  again  while  they  are  traversing  the  ampulla 
of  Vater.  If  they  are  of  any  size,  they  also  cause  painAvhile 
in  the  common  duct,  especially  at  first ;  and  if  the  common 
duct  is  blocked  by  a  calculus,  obstructive  jaundice  is  pro- 
duced. 

Rarely  a  calculus  may  ulcerate  through  the  wall  of 
the  gall-bladder  or  of  the  common  bileduct  and  may  reach 
the  intestine  in  this  manner  ;  it  may  even  cause  intestinal 
obstruction  as  practically  a  first  sign  of  its  existence.  The 
more  prominent  features  of  cholelithiasis  are  as  follows  : — 

(i.)  Attacks  of  Biliary  Colic.  These  come  on  suddenly, 
usually  for  no  apparent  reason — sometimes  two  to  three 
hours  after  food  ;  the  pain  is  most  acute  and  is  referred  for 
maximum  intensity  to  the  right  hypochondrium,  but  radiates 
over  the  abdomen  and  also  to  the  right  shoulder-blade. 

Each  attack  lasts  from  a  few  minutes  to  several  hours, 
and  as  a  rule  is  accompanied  by  vomiting.  The  stone 
may  slip  back  into  the  gall-bladder  or  be  passed  into  the 
common  duct  or  into  the  intestine,  when  the  pain  ceases. 

(ii.)  Intermittent  Pyrexia.  Shivering  attacks  are  of  fre- 
quent occurrence  in  gall-stones,  and  may  simulate  malaria. 
It  is  doubtful  whether  they  are  due  to  toxic  absorption  or 
to  nervous  influences  :  certainly  a  marked  cholecystitis 
or  chohmgitis    is    not  a  necessary  conconiitaiit.      Probably 


398  MEDICAL  DIAGNOSIS 

they  are  most  often  met  with  when  the  stones  are  in  the 
common  duct,  and  Osier  considers  the  following  association 
of  symptoms  to  be  practically  pathognomonic  of  calculi 
in  the  common  bileduct : — ■ 

(a)  Jaundice  of  varying  intensity,  persisting  for  a  long 
time. 

(6)  Ague-Hke  paroxysms,  after  each  of  which  the  jaun- 
dice deepens  for  a  time. 

(c)  Pains  in  the  region  of  the  liver  and  general  gastric 
disturbance  at  the  time  of  each  febrile  paroxysm, 
(iii.)  Jaundice.  So  long  as  the  stones  remain  in  the  gall- 
bladder there  will  be  no  jaundice,  but  when  they  reach 
the  common  duct  there  is  likely  to  be  some  obstruction 
to  the  flow  of  bile,  and  so  jaundice  occurs.  If  the  stone 
floats  in  the  common  duct,  there  need  be  no  jaundice.  If 
the  obstruction  remains  complete,  the  jaundice  steadily 
deepens  until  the  characteristic  olive-green  colour  develops. 
If  the  stone  passes  on  into  the  duodenum,  the  jaundice 
clears  up. 

(iv.)  Enlargement  of  the  Gall- Bladder .  It  is  rare  for  the 
gall-bladder  to  enlarge  when  the  common  duct  is  obstructed 
by  gall-stones,  whereas  enlargement  commonly  occurs  when 
the  common  duct  is  obstructed  by  new  growth  ;  pre- 
sumably the  reason  is  that  calculi  in  the  gall-bladder 
generally  cause  it  to  shrink  and  atrophy  so  that  it 
becomes  incajDable  of  dilatation. 

This  rule  is  known  as  Courvoisier's  law  and,  though  not 

invariable,  affords  great  help  in  the  differential  diagnosis. 

(v.)  Collapse.     Persons   suffering  from  biliary   colic   are 

often  profoundly  collapsed  ;   indeed,  feeble  individuals  may 

succumb  during  the  course  of  an  attack. 

(vi.)  Tenderness.  In  nearly  all  cases  definite  tenderness 
can  be  ehcited  by  pressing  firmly  along  the  line  joining  the 
ninth  costo-chondral  junction  with  the  umbihcus,  often  about 
the  junction  of  the  lower  and  middle  thirds  of  this  fine. 

(vii.)  Sometimes  the  presence  of  gall-stones  is  shown  by  no 
more  definite  signs  than  attacks  of  pain  in  the  upper  abdomen 
(not  necessarily  right  sided)  associated  with  distressing 
flatulence,  and  possibly  dark  urine  and  occasional  pale 
motions  but  no  jaundice  and  no  typical  biliary  colic. 


DISEASES   OF   THE   LIVER  399 

Diagnosis.  A  careful  consideration  of  the  above  features 
Avill  usually  make  the  diagnosis  clear,  but  at  first  sight  diffi- 
culty may  arise  in  the  following  cases  : — 

(a)  Appendicular  Colic.  There  is  no  pain  about  the 
right  scapula,  and  there  is  nearly  always  marked  tenderness 
in  the  right  iliac  fossa,  especially  over  McBurney's  spot 
(the  junction  of  outer  and  middle  thirds  of  the  line  joining 
the  anterior  superior  spine  of  the  ilium  to  the  umbilicus) . 
A  retro -csecal  appendix  may  cause  considerable  pain 
above  the  transverse  umbilical  level,  but  there  is  nearly 
always  tenderness  as  well  in  the  right  iliac  fossa. 

(6)  Duodenal  Ulcer.  The  pain  occurs  about  three  hours 
after  food  and  is  relieved  by  food  and  by  alkali.  Shiver- 
ing attacks  are  not  present. 

(c)  Tabetic  Crises.  There  is  no  jaundice  and  no 
shivering,  while  other  signs  of  tabes  dorsalis  will  be  found 
on  careful  examination. 

(d)  Intestinal  Colic.  There  are  no  true  paroxy sifts,  as 
in  biharj'  coUc,  rather  a  constant  pain  with  exacerbations  ; 
the  pain  is  not  so  locahsed  as  in  biliary  colic. 

(e)  New  Growth  in  Liver  {vide  p.  395). 

XI.    CHOLECYSTITIS. 

The  gall-bladder,  especially  when  it  contains  stones,  is 
liable  to  attacks  of  inflammation  which  closely  resemble 
affections  of  the  appendix  vermiformis  and  which  vary 
in  severity  from  simple  catarrh  to  gangrene  and  perforation. 
Not  only  is  the  pathology  similar,  but  the  symptoms  are 
identical,  if  we  remember  that  we  are  deahng  with  the  right 
hypochondrium  instead  of  the  right  iliac  fossa. 

.  XII.     CHOLANGITIS. 

(i.)  Catarrhal  Cholangitis  has  been  considered  under  the 
heading  of  "  Jaundice." 

(ii.)  Infective  Cholangitis  is  usually  the  result  of  a  non- 
suppurating  bacterial  infection  of  the  bileducts  supervening 
on  the  presence  of  calculi  in  the  common  bileduct.  The 
calcuH  are  not  usually  impacted,  so  that  they  act  as  an  inter- 
mittent ball-valve. 


400  MEDICAL   DIAGNOSIS 

Clinically  there  are  a  number  of  attacks  of  biliary  colic, 
usually  without  jaundice  ;  until  after  one  such  paroyxsni 
there  is  a  rigor.  Subsequently  rigors  occur  at  irregular  or 
regular  intervals  until  the  calculi  pass  or  are  removed  or 
imtil  death  occurs  from  the  development  of  a  suppurative 
process  or  from  toxaemia. 

Malaria  must  be  excluded  by  the  history  and  by  examina- 
tion of  the  blood  for  the  parasite. 

(iii.)  Suppurative  Cholangitis  usually  follows  gall-stones, 
but  may  occur  during  the  course  of  the  specific  infective 
diseases,  especially  enteric  fever,  or  as  an  accompaniment 
to  carcinoma  or  hydatid  cyst. 

The  following  symptoms  are  met  with  : — 

(«)  Evidence   of   septic    absorption,   such   as  irregular 

swinging  temperature,  perspirations,  rigors,  and  leucocy- 

tosis. 

(6)  Steady  increase  in  size  of  the  liver,  often  painless, 

unless  gall-stones  are  present,  when  paroxysmal  pain  is 

usual. 

If  the  trouble  is  not  due  to  gall-stones,  the  gall-bladder 

is  enlarged  also. 

(c)  Jaundice,  which  is  persistent  and  severe. 

Such  cases  present  a  great  similarity  to  suppurative 
pylephlebitis,  which  can,  however,  usually  be  distinguished 
by  the  lesser  degreee  of  jaundice  and  a  source  of  infection 
being  present  in  the  area  drained  by  the  portal  vein. 

DISEASES  OF  THE  PANCREAS. 

Inflammatory  affections  of  the  pancreas  may  be  acute 
or  chronic.  Acute  inflammations  may  be  hsemorrhagic  or 
non-haemorrhagic.  Chronic  inflammation  is  followed  by 
diffuse  fibrosis. 

I.  Acute  Hasmorrhagic  Pancreatitis.  Traumatic  causes 
ma}'-  induce  sudden  bleeding  into  the  substance  of  the 
pancreas,  but  apart  from  these  the  cause  of  such,  haemorrhage 
is  obscure.  Gall-stones  are  present  in  some  of  these  cases, 
and  it  has  been  suggested  that  one  factor  may  be  the 
regurgitation  of  bile  up  the  canal  of  Wirsung.  The  presence 
of  bile  in  the  pancreatic  duct  certainly  can  cause  acute 
inflammatory  changes. 


DISEASES   OF   THE   PANCREAS  401 

Theoretically,  at  any  rate,  hsemorrhage  may  follow  the 
liberation  of  the  pancreatic  juice  into  the  gland  interstitia, 
by  reason  of  its  digestive  powers,  and  such  liberation  may 
conceivably  occur  in  simple  inflammatory  pancreatitis  as  a 
result  of  rupture  of  small  retention  cysts. 

Arterial  degeneration  and  any  of  the  morbid  states  which 
favour  haemorrhage  may  be  factors  in  some  of  the  cases. 

Most  of  the  patients  are  fat.  Men  are  more  frequently 
affected  than  women,  and  the  average  age  is  30  to  50  years. 

Symptoms.  The  first  sign  is  a  sudden  and  extremely 
severe  abdominal  pain  followed  shortly  by  collapse  :  the 
pain  is  most  marked  in  the  epigastrium  or  round  the  umbiHcus. 
In  this  neighbourhood  there  is  great  tenderness  and  rigidity, 
while  distension  of  the  abdomen,  but  especially  of  the  upper 
part,  develops  in  a  few  hours.  Vomiting  sets  in  almost  at 
once  and  is  likely  to  continue,  but  does  not  become  fsecal 
in  character.  The  bowels  are  confined.  There  is  little  or 
no  pyrexia,  and  the  pulse  rarely  rises  to  more  than  100  per 
minute.     A  high  leucocytosis  is  the  rule. 

If  the  loss  of  blood  is  very  great,  the  signs  of  collapse  are 
especially  marked.  Death  usually  occurs  from  exhaustion 
about  the  third  day. 

Hsemorrhagic  pancreatitis  may  be  mistaken  for  : — 

(i.)  Acute  Intestinal  Obstruction.      At  first  differentia- 
tion may  be  impossible,  but  after  a  time  the  appearance 

of  fsecal  vomiting  and  the  very  rapid  pulse  would  suggest 

the  diagnosis. 

Epigastric  distension  and  possibly  a  palpable  epigastric 

tumour  from  the  effused  blood  are  much  in  favour  of 

pancreatitis. 

(ii.)  Superior  Mesenteric  Infarction.     The  presence  of 

a  cardiac  lesion  and  the  passage  of  blood  by  the  bowel 

may  help  in  this  case,  otherwise  the  early  symptoms  are 

identical. 

(iii.)   Rupture  of  a  Hollow  Viscus.     The  tenderness  and 

rigidity  are  more  diffuse,  while  unequivocal  evidence  of 

peritonitis  is  not  long  delayed. 

(iv.)  Biliary  Colic.     Jaundice,  if  ])resent.  is  a  valuable 

aid,  and  the  general  sym})toms  are  but  rarely  so  severe  as 

in  hsemorrhagic  pancreatitis. 
M.D.  26 


402  MEDICAL   DIAGNOSIS 

II.  Acute  Non-haemorrhagic  Pancreatitis.  The  etiology 
of  this  condition  is  obscure  ;  it  may  be  associated  with  gall- 
stones (about  40  per  cent.),  with  certain  specific  infections 
(mumps  or  enteric  fever),  with  embolism,  and  with  pancreatic 
calcuU.  A  certain  number  of  cases  may  be  due  to  the  spread 
of  organisms  up  the  canal  of  Wirsung  in  the  course  of  a 
duodenal  inflammation. 

Men  are  more  frequently  affected  than  women. 

All  stages  of  inflammation  may  occur,  from  simple  leuco- 
cytic  infiltration  to  gangrene. 

The  symptoms  and  signs  resemble  those  of  the  haemorrhagic 
form,  but  are  not  quite  so  sudden  in  onset.  They  often 
take  some  hours  to  reach  their  maximum,  and  there  may  be 
relative  intermissions. 

Rigors  are  not  unlikely  in  this  variety  ;  there  is  usually 
distinct  pyrexia,  and  the  pulse  tends  to  be  rapid. 

The  urine  occasionally  contains  sugar,  but  not  sufficiently 
often  for  its  presence  to  be  of  clinical  value. 

The  gland  may  become  so  swollen  as  to  obstruct  the 
common  bileduct  and  so  cause  jaundice.  A  palpable 
epigastric  tumour,  sometimes  sausage-shaped,  may  become 
apparent. 

The  differential  diagnosis  is  practically  the  same  as  for  the 
hemorrhagic  form. 

Some  cases  are  subacute  from  the  outset ;  others  start 
acutely  and  merge  into  a  subacute  or  chronic  form. 

III.  Chronic  Pancreatitis.  Some  of  these  cases  are 
definitely  infective,  and  have  been  shown  to  be  due  to  the 
Bacillus  typhosus  or  to  the  Bacillus  coli  ;  others  must  be 
regarded  as  toxic,  and  in  all  probabihty  the  same  factors 
which  produce  cirrhosis  of  the  liver  can  produce  a  similar 
change  in  the  pancreas.  It  is  thought  that  the  toxins  of 
the  tubercle  bacillus  may  be  eliminated  in  the  pancreatic  juice 
and  may  cause  irritation  of  the  organ  during  their  excretion. 

Pancreatic  calculi  may  cause  fibrosis  by  damming  up 
secretion  just  as  gall-stones  may  cause  obstructive  biliary 
cirrhosis. 

Lastly,  in  common  with  all  other  organs  of  the  body,  the 
pancreas  may  become  fibrosed  from  simple  senile  vascular 
changes. 


DISEASES   OF   THE   PANCREAS  403 

The  sexes  seem  to  be  affected  equally,  and  the  disease  is 
most  usual  in  the  second  half  of  life. 

Symptoms.  Many  case.s  give  rise  to  no  symptoms  and 
are  only  discovered  after  death. 

Such  symptoms  as  may  be  present  are  wasting,  lack  of 
appetite,  and  alteration  in  the  character  of  the  faeces. 
Jaundice  is  frequently  present,  and  is  likely  to  be  accom- 
panied by  a  palpable  gall-bladder.  There  are  likely  to  be 
general  dyspeptic  phenomena,  and  bouts  of  severe  abdominal 
pain  are  not  infrequent. 

A  certain  proportion  of  cases  of  chronic  pancreatitis  ulti- 
mately develop  diabetes. 

Since  disturbance  of  the  pancreatic  function  results  in 
disordered  fat  digestion,  the  motions  contain  an  excess  of 
fat  and  are  pale,  bulky,  offensive  and  greasy.  The  impor- 
tant point  seems  to  be  an  increased  proportion  of  neutral 
fat  as  compared  with  fatty  acids. 

A  lack  of  bile  produces  a  similar  but  less  marked  condition, 
but  the  motions  in  this  case  are  generally  acid,  whereas 
they  are  alkaline  when  the  pancreas  is  at  fault.  Further, 
pancreatic  disability  is  shown  by  the  presence  of  undigested 
muscle  fibres  in  the  faeces. 

Cammidge's  test  is  thought  by  some  to  furnish  reliable 
evidence  of  active  pancreatic  disease.  It  is  said  not  to 
occur  in  cases  of  simple  fibrosis  or  of  blocked  secretion. 

It  appears  to  depend  on  the  presence  in  the  urine  of  these 

cases  of  a  substance  which  is  probably  "  pentose."     In  its 

simplest  form  the  reaction  may  be  performed  as  follows  : — 

Filter  a  twenty-four  hours  specimen  of  urine,  and  remove 

albumin  and  sugar  if  such  be  present. 

Add  to  20  cc.  of  the  filtrate  1  cc.  of  strong  hydrochloric 

acid.     Boil  gently  for  ten  minutes  and  cool  under  the  tap. 

Make  up  the  solution  to  20  cc.  with  distilled  water  and 

add  4  grms.  of  lead  carbonate. 

Shake  till  no  more  gas  is  evolved  and  filter. 

Add  4  grms.  of  tribasic  lead  acetate. 

Shake  :  allow  to  stand  for  a  few  minutes  and  filter. 

Add  2  grms.  sodium  sulphate. 

Shake  for  several  minutes  and   (hen  bring  slowly  to 

boiling  point  on  a  sand  bath, 

26—2 


404  MEDICAL   DIAGNOSIS 

Cool  under  the  tap  and  filter  yet  again. 
Of  this  filtrate  take  10  cc.  and  make  up  to  18ce,  with 
distilled  water. 

Add  to  this  solution  '8  grm.  phenylhydrazine  hydro- 
chlorate,  2  grms.  sodium  acetate,  1  cc.  of  50  per  cent, 
acetic  acid. 

Boil  gently  on  a  sand  bath  for  ten  minutes. 
Filter  through  filter  paper  moistened  withboihng  water. 
Measure  the  filtrate,  and  if  it  is  less  than  15  cc.  make  up 
to  this  bulk  with  distilled  water. 

Place  this  final  solution  in  an  ice-chest  for  four  hours. 
In  a  positive  reaction  there  will  be  an  ample  deposit 
of  circular  tuft-like  ozazone  crystals,  which  should  be 
examined  microscopically  and  which  should  disappear  in 
ten  to  fifteen  seconds  if  some  33  per  cent,  sulphuric  acid 
be  run  under  the  cover-slip. 

A  positive  Cammidge  reaction,  hke  glycosuria,  is  con- 
firmatory evidence  of  pancreatitis  either  acute  or  chronic  ; 
a  negative  reaction,  like  the  absence  of  sugar  from  the 
urine,  is  of  little  or  no  value. 

Cammidge  has  also  evolved  a  satisfactory  technique  for 
the  estimation  of  neutral  fat  and  fatty  acids  in  the  faeces, 
but  the  technique,  which  involves  very  accurate  gravimetric 
processes,  is  hardly  practicable  except  in  a  fully  equipped 
laboratory. 

The  following  test  has  recently  been  elaborated  in  the 
effort  to  arrive  at  some  means  of  more  accurately  gauging 
the  efficiency  of  the  pancreas  :  it  is  likely  to  prove  of  con- 
siderable value  in  the  diagnosis  of  certain  cases  of  pancreatic 
disease  and  also  in  certain  cases  of  renal  disease  : — 

The  diastase  reaction.  There  is  normally  present  in  the 
blood  a  certain  amount  of  diastase  some  of  which  is  excreted 
with  the  urine. 

In  health  the  quantity  in  the  urine  is  fairly  constant,  but 
in  disease,  especially  of  the  pancreas  and  the  kidneys,  there 
is  much  variation  in  the  amount  found. 

Technique.     Three  solutions  are  required  : — 
(i.)  A  1  per  cent,  solution  of  sodium  chloride, 
(ii.)  A    0-1    per    cent,    solution    of    "soluble    starch" 
(Kahlbaum).     The    solution   is  prepared  by  stirring  the 


DISEASES   OF   THE   PANCREAS  405 

starch  into  the  water  as  it  boils  in  a  beaker.     It  sliould 

be  prepared  fresh  every  day,  as  the  starch  tends  to  separate 

out  on  standing. 

N 
(iii.)  A    —    solution    of   iodine.     This   is    an   unstable 
50 

solution.     It  should  be  made  up  fresh  as  required  from  a 

decinormal  solution  which  is  stable. 

A  series  of  ten  test  tubes  is  taken. 

With  a  graduated  1  cc.  pipette  the  following  amounts  of 

urine  (24  hours  specimen)  are  delivered  : — 

(i.)  0-6  cc.  urine. 

(ii.)  0-5  cc.      ,, 

(iii.)  0-4  cc.       ,, 

(iv.)  0-3  cc.      „ 

(V.)  0-2  cc.      „ 

(vi.)  0-1  cc. 


(vii.)  0-09  cc. 


r  These  latter  small  amounts  are  best 
,...,„„„  added  by  means  of  a  1  in  10  dilution 

(Vm.)    0-08  cc.        „       J       c  •  IJ-  •       ^       J       £    n  nn 

,.     :   „  ^_  ^  of  unne,  addmg  mstead  of  0-09  cc. 

(ix.)  0-07  cc.  „         ,.        ,.;  ,    ,     *.       ^^  £  ^, 

,    :   „  „  „  of   undiluted   urme    0-9   cc.    of   the 

(x.)  0-06  cc.  „         ,.,   , .  , 

^    '  ^  dilution,  etc. 

The  amount  in  each  tube  is  made  up  to  1  cc.  with  the 
saline  solution  and  to  each  tube  is  added  2  cc.  of  the  starch 
solution.  The  salt  and  starch  are  best  delivered  from 
burettes  graduated  in  tenths  of  a  cubic  centimetre. 

The  tubes  are  now  labelled  and  placed  in  a  water  bath  at 

39°  C.  for  half  an  hour.     They  are  then  placed  in  cold  water 

for  a  few  minutes  to  stop  the  ferment  action,  and  to  each 

N 
tube  is  added  a  drop  of  the  —  iodine  solution. 
^  50 

The  tube  containing  the  greatest  amount  of  urine  in  which 
a  mauve  colour  is  produced  is  noted  ;  it  is  called  the  "  limit 
tube."     In  a  normal   urine  this  is  commonly  the  0-1   cc 
tube.     In  the  tube  next  above  this  (the  0-2  cc.  tube)  ail  the 
starch  has  been  converted  by  the  ferment. 

0-2  cc.  of  urine  will  convert  2  cc.  of  the  starcii  solution  : 
therefore,  1  cc.  of  urine  will  convert  10  cc.  of  the  starch 
solution.     This  number  10  is  known  as  the  diastase  number. 

In  health  the  diastase  number  varies  sonicAvhere  l)etween 
10  and  30. 


406  MEDICAL   DIAGNOSIS 

The  test  is  particularly  applicable  to  disease  of  the  pancreas 
in  which  there  is  some  obstruction  to  the  dnct  (in  which 
case  there  is  more  diastase  passed  into  the  blood  and  so  into 
the  urine),  and  to  renal  disease  where  there  is  difficulty  of 
elimmation  due  to  organic  change  in  the  kidney  (in  which 
case  less  diastase  appears  in  the  urine). 

It  has  been  used  as  a  test  of  renal  function  in  comparing 
specimens  from  ureteric  catheterisation  of  both  kidneys, 
always  provided  that  the  two  ureters  are  catheterised  simul- 
taneously. 

The  features  which  suggest  pancreatic  disease  have  been 
indicated  above  ;  but  it  will  be  obvious  that  it  may  be  very 
difficult  to  exclude  certain  affections  of  the  liver  and  bile- 
ducts.  Again,  when  pancreatic  disease  has  been  diagnosed 
it  may  be  difficult  to  say  whether  it  is  innocent  or  malignant. 

IV.  Tumours  of  the  Pancreas,  (i.)  Cystic  Tumours. 
So-called  pancreatic  cysts  are  usually  peri-pancreatic  and 
due  to  the  collection  of  fluid  in  the  lesser  sac  of  the  peri- 
toneum after  blocking  of  the  foramen  of  Winslow. 

True  retention  cysts  of  the  pancreas  do,  however,  occur, 
especially  in  conjunction  with  chronic  pancreatitis. 

Some  writers  hold  that  all  pancreatic  cysts  are  really 
hsemorrhagic  in  origin. 

The  symptoms  vary  with  the  causes  of  the  cyst ;  in  many 
cases  a  tumour  is  the  first  thing  complained  of. 

The  characteristic  tumour  is  smooth  and  rounded,  it 
moves  slightly,  is  dull  to  percussion,  and  may  give  a  trans- 
mitted impulse  from  the  aorta,  but  is  not  expansile  and  does 
not  give  a  thrill. 

It  first  presents  below  the  left  ribs,  and  may,  as  it 
increases  in  size,  fill  the  whole  of  the  upper  part  of  the 
abdomen. 

If  the  size  of  the  tumour  increases  rapidly,  haemorrhage 
into  it  is  probable.  When  very  large,  it  may  interfere  with 
the  diaphragm  and  press  on  adjacent  structures,  such  as  the 
portal  vein  and  intestines,  which  indeed  may  become 
obstructed. 

The  cyst  does  not  often  reach  any  great  size  without  causing 
pain  in  the  epigastrium  and  marked  digestive  disturbance. 

Those  cases  which  are  due  to  retention  cysts  resulting  from 


DISEASES   OE   THE   PA^X'REAS  407 

chronic  j^ancreatitis  give  the  cHnical  manifestations  of  this 
condition  often  before  the  tumour  is  apparent  {vide  p.  402), 
and  where  the  main  duct  is  obstructed  there  is  hkely  to 
be  jaundice  vomiting  and  paroxj^smal  pain. 

When  once  the  tumour  can  be  recognised  its  diagnosis 
is  not  difficult  ;  it  generally  appears  between  the  stomach 
and  the  colon,  and  thes-e  organs  can  be  demonstrated  after 
inflation  lying  respectively  above  and  below  the  dull  globular 
mass. 

(ii.)  Solid  Tumours  of  the  Pancreas.  Chnically  the  only 
important  solid  tumour  of  the  pancreas  is  carcinoma. 

This  is  usually  situated  in  the  head  of  the  pancreas  and 
is  for  a  long  time  painless. 

In  addition  to  the  constitutional  signs  common  to  all 
malignant  disease  carcinoma  of  the  pancreas  is  generally 
associated  with  the  clinical  phenomena  of  pancreatitis 
{vide  p.  402),  and  also  with  jaundice  of  obstructive  type  and 
with  an  enlarged  gall-bladder.  In  addition  to  the  enlarged 
gall-bladder  the  main  growth  may  be  palpable  as  a  tumour 
in  the  neighbourhood  of  the  pyloric  end  of  the  stomach, 
from  which  it  is  often  indistinguishable,  and  which,  indeed, 
is  often  implicated  by  direct  extension. 

The  liver  is  generally  the  site  of  secondary  deposits,  so 
that  the  features  of  carcinoma  of  the  liver  may  be  super- 
added. 

In  the  earliest  stages  the  diagnosis  rests  upon  : — 

(a)  Rapid  emaciation  and  increasing  muscular  weakness. 
(6)  Painless  jaundice, 
(c)  Palpable  gall-bladder. 

The  short  history  will  usually  serve  to  exclude  chronic 
pancreatitis. 

A  positive  diagnosis  is  of  value,  since  when  it  is  possible  a 
])atient  may  be  spared  a  useless  laparotomy. 


CHAPTER   II 

EXAMINATION    AND    ANALYSIS    OF   URINE 

I.    GENERAL   CONSIDERATIONS. 

The  diagnostic  value  of  urinary  examination  can  hardly 
be  over-estimated  ;  it  is  a  procedure  which  should  never 
be  omitted,  no  matter  how  improbable  it  may  appear 
that  anything  abnormal  will  be  found. 

In  the  present  chapter  the  chief  properties  of  the  urine, 
normal  and  pathological,  will  each  be  considered  briefly 
from  the  point  of  view  of  their  diagnostic  significance,  and 
the  simple  tests  which  are  needful  for  their  respective 
investigations  will  be  discussed. 

Whenever  possible  a  sample  of  the  mixed  specimens  of 
all  the  urine  passed  during  the  twenty -four  hours  should  be 
used  for  all  examinations,  except  microscopical.  In  the 
latter  case  the  urine  should  be  examined  as  soon  as  possible 
after  being  passed.  If  the  urine  has  to  be  sent  away  for 
examination  it  should  be  placed  in  a  sterile  stoppered 
bottle  and  a  few  cubic  centimetres  of  chloroform  added  to 
it  for  chemical  examinations,  while  for  examination  of 
sediments  a  few  drops  of  formalin  may  be  substituted. 
For  bacteriological  purposes  a  catheter  specimen  should 
be  received  in  a  sterile  vessel  and  sealed  up  immediately 
without  the  addition  of  any  preservative. 

The  amount  of  urine  passed  in  twenty-four  hours  varies 
between  1,000  and  2,000  cc.  ;  the  average  usually  given  is 
1,500  cc,  though  this  is  probably  rather  high. 

In  health  more  urine  is  secreted  in  the  daytime  than  at 
night,  but  the  converse  obtains  in  cases  of  interstitial 
nephritis. 

The  urinary  output  depends  on  the  nature  of  the  solids  to 
be  excreted  and  also  on  the  rate  of  the  blood  flow  through 


EXAMINATION  AND   ANALYSIS   OF   URINE     409 

the    renal    arteries  ;    high    blood    pressure     only    causes 
polyuria  if  it  increases  the  rate  of  the  blood  flow. 

The  amount  of  urine  is  increased  in  chronic  interstitial 
nephritis,  diabetes  mellitus,  diabetes  insipidus,  hysteria 
and  certain  cerebral  lesions  ;  also  in  cold  weather,  after 
the  ingestion  of  much  fluid,  and  during  convalescence  from 
acute  infections.  It  is  decreased  in  acute  nephritis, 
chronic  tubal  nephritis,  where  there  is  anasarca  or  a 
serous  exudate,  in  high  fever,  and  when  there  is  very  free 
perspiration. 

Specific  Gravity.  If  water  is  1,000,  the  normal  specific 
gravity  of  urine  is  1,020  at  the  ordinary  room  temperature. 
The  urine  of  infants  is  normally  about  1,007. 

The  specific  gravity  is  liigh  in  concentrated  urines,  and 
if  there  are  abnormal  constituents  present,  such  as  sugar  or 
albumin,  except  when,  in  the  latter  case,  the  high  solid 
content  is  more  than  counterbalanced  by  the  increase  of 
watery  matter.  In  the  case  of  sugar  the  polyuria  is/rarely 
sufficient  to  induce  a  low  specific  gravity.  Low  specific 
gravities  depend  almost  entirely  on  an  excessive  output  of 
watery  urine. 

If  the  last  two  figures  of  the  specific  gravity  are  multiplied 
by  the  arbitrary  coefficient  23,  an  approximate  estimate  of 
the  sohds  in  the  urine  will  be  found  expressed  in  grammes 
per  litre. 

Colour.  The  natural  colour  of  urine  is  some  variety  of 
yellow,  and  the  more  watery  the  urine  the  paler  the  colour, 
except  in  diabetes.  Acid  urines  are  usually  darker  than 
alkaline,  and  the  urine  of  ursemia  is  often  peculiarly  pale. 
Febrile  urines  are  dark  owing  to  concentration. 

The  urinary  pigments  normally  present  are  urochrome, 
urobihn,  and  ha?matoporphyrin.  Urobilin  is  not  present 
as  such  when  the  urine  is  passed,  but  is  soon  formed  by  the 
action  of  light  on  urobilinogen.  Uroerythrin  is  frequently 
present  in  urines  which  are  rich  in  urates.  LTrobilin  maj^  bo 
tested  for  as  follows  : — 

(i.)  Add  excess  of  ammonia  and  then  a  few  drops  of  a 
1  per  cent,  solution  of  zinc  chloride  :  a  green  fluorescence 

indicates  urobilin. 

(ii.)    Add  a  few  drops  of  tincture  of  ioJine  to  10  cc.  of 


410  MEDICAL   DIAGNOSIS 

the  urine  and  examine  with  the  spectroscope  :  a  band 

between  the  green  and  bhie  indicates  urobiKn. 

The  colour  of  urine  may  be  affected  by  the  presence  of  the 
following  abnormal  constituents  : — • 

Blood  and  its  Derivatives.  Urine  which  contains  blood 
varies  in  colour,  according  to  the  amount  of  blood  present, 
from  reddish-brown  to  a  faint  smoky  tinge.  Methsemo- 
globin  causes  a  brown  rather  than  a  red  tinge,  and  haemo- 
globin, as  seen  in  blackwater  fever  and  paroxysmal  haemo- 
globinuria,  causes  the  urine  to  appear  greenish  black  when 
present  in  large  amount.  Haematoporphyrin,  when  present 
in  considerable  quantities,  as  in  cases  of  sulphonal  poisoning, 
imparts  a  dark  violet  colour  to  the  urine. 

Bile.  When  jaundice  is  at  all  marked  bilirubin  and 
biliverdin  are  usually  present  in  the  urine,  and  the  colour 
is  brown,  green,  or  even  greenish-black.  If  the  urine  is 
shaken,  even  small  quantities  of  bile  will  give  a  yellow 
coloration  to  the  foam  which  is  characteristic. 

Melanin.  This  pigment  has  been  found  in  certain  cases 
of  melanotic  growths  in  the  viscera,  especially  in  the  liver  ; 
it  is  not  commonly  present  when  the  urine  is  passed,  but  is 
formed  soon  after  passing  by  oxidation  of  its  precursor 
melanogen. 

Ferric  chloride  causes  immediate  darkening  of  such  a 
urine,  and  a  grey  precipitate  is  formed  which  is  soluble  in 
excess  of  the  reagent  (von  Jaksch). 

Drugs.  When  the  urine  is  of  a  striking  colour  careful 
inquiry  should  be  directed  to  the  recent  drug  history. 
Methylene  blue,  even  in  minute  doses,  imparts  a  greenish 
blue  colour  to  the  urine.  Carbolic  acid  and  other  coal-tar 
derivatives  often  cause  marked  darkening  of  the  urine  ; 
the  coloration  may  not  appear  till  the  urine  has  stood  a 
long  time  and  has  become  alkaline.  The  colouring  matter 
is  usually  pyrocatechin  or  hydroquinone.  These  bodies 
reduce  copper,  but  not  bismuth. 

Rhubarb,  santonin,  senna,  and  other  drugs  containing 
chrysophanic  acid  impart  a  bright  yellow  colour  to  acid  and 
a  reddish  tinge  to  alkaline  urine. 

Reaction.  Urine  is  normally  acid,  owing  to  the  presence 
of  acid  sodium  phosphate,  except  for  a  short  time  about 


EXAMINATION   AND   ANALYSIS   OF   URINE     41] 

two  hours  after  a  good  meal,  when  the  reaction  is  temporarily 
alkaline  (the  alkaline  tide). 

The  acidit}^  is  rarely  very  great  and  varies  markedly  with 
the  proteid  intake.  (To  estimate  the  total  acidity,  vide 
p.  413.) 

Alkalinity  of  the  urine,  if  caused  by  volatile  alkali 
(ammonia),  is  always  due  to  bacterial  decomposition.  Red 
litmus  will  be  turned  blue  if  hinig  over  the  mouth  of  a  bottle 
containing  urine  which  is  alkaline  from  excess  of  ammonia ; 
but  this  colour  change  is  not  produced  by  fixed  alkali  unless 
the  htmus  paper  is  dropped  into  the  urine  or  allowed  to 
remain  suspended  above  it  for  a  prolonged  time. 

Smell.  The  odour  of  decomposing  alkaline  urine  is 
ammoniacal  ;  normal  urine  has  but  little  odour.  Acetone 
imparts  a  striking  smell  of  apples  and  chloroform  to  the 
urine.  The  smeU  of  the  oleo-resins  can  readily  be  appreciated 
in  the  urine,  and  a  smell  of  violets  is  produced  by  the 
ingestion  of  turpentine.  / 

Translucency.  Healthy  urine  is  clear  when  freshly  passed  ; 
as  it  cools  urates  may  be  deposited,  pink  in  adults,  but  often 
white  in  childhood,  or  a  cloud  of  mucus  may  appear  in  the 
upper  layers  of  the  fluid.  Definite  cloudiness  when  passed 
may  be  due  to  an  excess  of  phosphates  in  alkaline  urine,  to 
pus,  or  to  bacteria.  Pus  and  phosphates  will  settle  to  the 
bottom  of  the  vessel,  but  bacteria  will  keep  the  urine  per- 
manently cloudy. 

II.    NORMAL  URINARY  CONSTITUENTS. 

(i.)  Nitrogenous  Bodies.  The  nitrogen  output  is  made  up 
in  four  ways,  and  the  average  on  a  full  proteid  diet  is  as 
follows  (Folin)  : — 

Urea      .  .  .  .  .  .  .  .  87  per  cent. 

Ammonia  .  .  .  .  .  .  8    ,,      ,, 

Uric  acid  .  .  .  .  .  .  2    ,,      ,, 

Extractives  . .  . .  . .  8    „      ,, 

The  total  amount  is  about  16  grms.  of  nitrogen  daily. 
The  nitrogen  output  is  high  in  fevers,  in  cachexia,  in 
diabetes,  after  protoplasmic  poisons  such  as  phosphorus  or 


412 


MEDICAL   DIAGNOSIS 


i 


/ 


arsenic,   and  also  where  large  inflammatory  exudates  are 
in  process  of  absorption. 

The  nitrogen  output  is  notably  diminished  in  nephritis, 
though  in  such  cases  nitrogen  equilibrium  may,  to  some 
extent,  be  maintained  by  an  increased  output  in  the  faeces. 

The  estimation  of  the  total  nitrogen  output  involves  a 

somewhat  laborious  technique  (Kjeldahl's  method)  and  is  not 

often  necessary   in  clinical  work.     The 

urea  estimation   (so   called)  is  generally 

a  sufficient  guide. 

Urea.  The  daily  output  of  urea  varies 
from  20  to  40  grms.  and  averages  about 
2  per  cent,  of  the  urine.  It  depends 
largely  on  the  nature  of  the  diet,  and 
it  should  always  be  borne  in  mind  that 
this  may  influence  the  value  of  a  urea 
estimation. 

The  most  convenient  methods,  for 
clinical  use,  of  investigating  the  urea 
output  are  those  of  Gerrard  or  Doremus, 
though  other  nitrogen  than  that  of  urea 
is  included  in  the  estimate.  More 
accurate  investigation  nnist  be  left  to  a 
highly-skilled  chemist. 

Both  Gerrard's  and  Doremus's  methods 
depend  on  the  decomposition  of  urea 
by  an  alkaline  hypobromite  solution  and 
the  consequent  liberation  of  COg,  which 
is  allowed  to  displace  water  in  a  vessel 
graduated  in  such  a  way  as  to  permit 
of  the  resulting  fluid  Mevel  being  read  off  as  the  per- 
centage of  urea  in  the  urine. 

The  hypobromite  solution  must  be  freshly  made  for  each 
experiment  by  adding  2  cc.  of  liquid  bromine  to  23  cc.  of 
40  per  cent,  aqueous  sodium  hydrate  solution. 

The  necessary  amount  of  urine  (5  cc.  for  Gerrard's  test)  is 
carefully  measured  from  a  twenty -four  hours  specimen  before 
being  added  to  the  hypobromite  in  the  specially-devised 
apparatus. 

The  instrument  devised  by  Doremus  is  easy  of  application 


Fig.  54  —The   Ureo- 
meter  of  Doremus. 


EXAMINATION  AND   ANALYSIS   OF  URINE     413 

and  reasonably  accurate.  It  consists  (Fig.  54)  of  a  graduated 
tube  closed  at  one  end  and  ha\ang  the  other  end  bent  in 
U-shape  and  expanded  to  a  bulb.  There  is  also  a  pipette 
graduated  to  contain  1  cc. 

The  bulb  is  filled  with  hypobromite  solution,  being  tilted 
the  while  to  expel  all  air.  The  pipette  is  filled  with  urine 
to  the  mark,  and  this  urine  is  expelled  into  the  long  limb  of 
the  ureometer.  The  liberated  nitrogen  collects  at  the  top 
of  the  tube  and  the  level  of  the  gas  is  read  off  on  the  scale, 
which  is  so  graduated  as  to  read  either  the  percentage  of 
urea  or  the  amount  in  grains  per  ounce. 

Although  the  urea  percentage  permits  of  wide  variations 
in  health  it  is  not  advisable  to  perform  any  major  surgical 
operation  when  the  reading  is  under  '6  per  cent. 

Ammonia  Nitrogen.  The  importance  of  this  method  of 
nitrogen  excretion  is  becoming  more  widely  recognised.  The 
normal  amount  of  ammonia  in  the  urine  is  approximately 
•7  grm.,  or  4  per  cent,  of  total  nitrogen  :  this  is  increase'd  on  a 
very  fatty  diet  and  after  the  intake  of  organic  and  sometimes 
of  inorganic  acids  ;  it  is  often  high  in  diabetes  and  any 
case  of  oxygen  starvation.  Any  big  increase  is  accompanied 
by  toxic  symptoms,  and  in  fatal  cases  focal  necrosis  has  been 
found  in  the  liver. 

Perhaps  the  most  practical  use  of  the  above  has  been 
found  in  cases  of  pernicious  vomiting  of  pregnancy  ;  in 
these  there  is  a  very  high  ammonia  output,  whereas  in  other 
forms  of  vomiting  associated  Avith  pregnancy  there  is  iiot. 
Hence  there  is  a  definite  indication  for  emptying  the  uterus 
when  the  ammonia  nitrogen  percentage  reaches  10  to  12  per 
cent. 

Fortunately  there  is  a  fairly  simple  method  for  estimating 
the  ammonia  content  of  the  urine.  The  first  stage  is  that 
usually  adopted  for  estimating  the  total  acidity  and  is  as 
follows  : — To  25  cc.  of  freshly-voided  urine  add  an  equal 
bulk  of  distilled  water,  15  grms.  of  neutral  potassium  oxalate, 
and  '5  cc.  of  phenolphthalein  solution  ;  shake  the  mixture 
thoroughly  till  the  oxalate  is  dissolved  and  then  titrate 
with  decinormal  caustic  soda  until  a  very  faint  pink  colour 
a]>])ears.  The  luimber  of  cubic  oentiiuetres  oi  caustic  soda 
used  represents  the  total  acidity  of  the   urine.     For  the 


414  MEDICAL   DIAGNOSIS 

estimation  of  the  ammonia  first  neutralise  10  cc.  of  20  per 
cent,  formalin  with  the  phenolphthalein  and  caustic  soda 
solution  and  add  this  to  the  already  neutralised  urine.  This 
causes  the  pink  colour  to  disappear,  and  a  further  quantity 
of  the  standard  soda  solution  must  now  be  added  to  cause 
the  reappearance  of  the  pink  tint.  The  extra  amount  of 
caustic  soda  which  it  has  been  necessary  to  use  (in  cubic 
centimetres)  multiplied  by  -0014  represents  the  amount  of 
nitrogen  present  as  ammonia  in  the  original  25  cc.  of  urine 
taken. 

N.B.  The  end  points  in  these  reactions  are  rendered 
more  distinct  by  the  precipitation  of  the  calcium  phos- 
phate by  the  preliminary  addition  of   oxalate  ;  it  is  also 
important  to  add  not  less  than  "5  cc.  of  the  indicator. 
Uric  Acid.     This  substance  is  only  present  to  the  amount 
of  about  '7  grm.  daily,  and  is  produced  for  the  most  part 
by  oxidation  of  nuclein  bases,  both  endogenous  and  exo- 
genous.    Very  little  is  known  concerning  the  significance 
of  its  increased  production,  and  in  all  probability  little  or  no 
information  is  gained  by  its  quantitative  estimation.     It  is 
increased  pari  passu  with  urea  in  febrile  states,  and  also 
in  leukaemia,  diabetes,  and  cirrhosis  of  liver.     With  regard 
to  gout,  the  uric  acid  output  is  lessened  between  the  attacks 
but  above  normal  during  the  exacerbations. 

The  endogenous  uric  acid  is  the  important  factor,  and  in 
order  that  any  value  whatever  may  be  elicited  by  the 
quantitative  estimation  of  the  uric  acid  output  the  patient 
should  be  on  a  nuclein -free  dietary  so  as  to  control  the 
exogenous  production. 

The  presence  of  uric  acid  may  be  demonstrated  by  the 
murexide  test  : — Evaporate  some  urine  in  a  porcelain  basin 
and  dissolve  some  of  the  residue  in  a  few  drops  of  nitric  acid  ; 
again  evaporate  slowly  to  dryness,  when  a  red  coloration 
occurs.  If  ammonia  now  be  added  the  red  colour  becomes 
tinged  with  purple. 

An  accurate  quantitative  determination  requires  a  very 
compUcated  technique,  but  a  rough  estimation  may  be 
made  as  follows  : — Divide  the  lower  half  of  a  test  tube 
into  seven  equal  parts  ;  fill  up  to  the  second  mark  with 
pure  nitric   acid ;    pour   the    urine   previously  freed  from 


EXAMINATION  AND   ANALYSIS   OF   URINE     415 

albumin  gently  on  to  the  nitric  acid  tiU  it  reaches  the  seventh 
mark.  If  the  cloudy  ring  of  urates  appears  above  the  line 
of  junction  before  five  minutes  has  elapsed,  the  uric  acid 
is  increased  ;  if  the  cloud  is  delayed  much  more  than  five 
minutes,  the  uric  acid  is  diminished  (Heller). 

The  amount  of  uric  acid  seems  to  vary  inversely  with  that 
of  the  purin  bases. 

(ii.)  Chlorides.  From  10  to  15  grms.  of  chlorides  are  excreted 
daily  in  the  urine.  The  chief  importance  of  the  chlorides 
seems  to  be  their  relation  to  serous  and  fibrinous  exudations. 
They  are  diminished  or  absent  in  cases  of  exudation,  notably 
in  pneumonia,  but  their  output  soon  returns  to  normal  as 
the  exudate  commences  to  be  absorbed. 

This  chloride  retention  is  very  remarkable  and  has  not 
been  fully  explained  ;  there  is  evidence  to  show  that  the 
cldoride.s  are  accumulated  in  the  tissues  rather  than  in  the 
blood.  These  facts  have  led  to  the  advocacy  of  salt-free 
diet  in  cases  of  cardiac  and  renal  oedema,  and  in>certain 
cases  there  is  no  doubt  that  the  oedema  can  be  lessened  if 
chlorides  are  withheld  from  the  food. 

An  accurate  quantitative  determination  of  chlorides  is 
not  of  clinical  importance,  but  the  fact  of  their  diminution 
or  otherwise  can  readily  be  estimated  as  foUows  : — First 
free  the  urine  from  albumin  by  boiling  and  filtration  ; 
then  add  to  a  test  tube  half-full  of  this  about  8  drops  of  nitric 
acid  ;  and  finally  add  2  or  3  drops  of  10  per  cent,  silver 
nitrate  solution.  If  the  chlorides  are  normal,  a  thick, 
fiocculent  precipitate  is  formed  ;  if  decreased,  the  precipitate 
is  much  less  thick,  or  only  a  cloudiness  may  be  noticed. 
It  is  convenient  to  perform  a  control  experiment  with  a 
known  normal  urine. 

This  question  of  chloride  diminution  is  often  of  importance 
in  the  diagnosis  of  pneumonia,  but  it  must  be  remembered 
that  it  is  not  pathognomonic,  for  pleurisy  with  effusion 
or  any  serous  exudate  may  produce  almost  the  same  effect. 

(iii.)  Phosphates.  These  ma}^  occur  up  to  5  grms.  daily. 
Uoth  the  earthy  phosphates  of  calcium  and  magnesium 
and  the  alkaline  sodium  and  ammonium  phosphates  are 
found.     Organic  phosphates  also  occur  in  minute  amounts. 

TJu!  presence  of  phosph£(,tes  is  not  of  any  special  diagnostic 


416  MEDICAL  DIAGNOSIS 

significance,  though,  of  late,  it  has  been  found  that  some 
cases  of  neurasthenia  are  associated  with  a  largely  increased 
output,  and  in  some  of  these  the  phosphoric  acid  is  decreased 
while  the  output  of  calcium  is  greatly  increased.  These 
facts,  if  true,  are  of  great  interest  in  that  appropriate 
treatment  readily  suggests  itself. 

Calcium  phosphate  is  precipitated  by  heat  and  may  be 
mistaken  for  albumin  ;  the  precipitate,  however,  at  once 
disappe.ars  when  a  drop  of  acid  is  added. 

(iv.)  Sulphates.  These  are  present  to  the  extent  of  about 
2'5  grms.  daily  in  tlie  urine.  As  their  production  depends 
on  the  metabolism  of  proteid  matter  they  commonly  bear  a 
constant  ratio  to  the  nitrogen  output. 

Their  most  interesting  aspect  lies  in  the  fact  that  a  varying 
proportion  of  them  (about  one  tenth  normally)  is  excreted 
in  combination  with  an  aromatic  base.  The  amount  of 
these  so-called  ethereal  sulphates  is  thought  to  furnish  a 
direct  index  of  the  amount  of  intestinal  decomposition  that 
is  taking  place.  Gastric  disturbances  do  not  seem  to  affect 
them  :  alkalies  increase  them,  while  acids  and  intestinal 
antiseptics,  except  possibly  carbolic  acid,  diminish  their 
production. 

The  procedure  for  the  estimation  of  ethereal  sulphates 
in  the  urine  is  chemically  too  technical  to  be  described  here  ; 
but  an  idea  as  to  whether  they  are  increased  or  not  can 
be  formed  by  the  consideration  of  the  urinary  pigment 
indoxyl  sulphate,  or  indican  as  it  is  sometimes  called. 

The  presence  of  this  body  can  be  shown  by  Jaffe's  test. 
Any  albumin  that  is  present  must  be  removed  by  boiling 
and  filtering.  Then  into  10  cc.  of  urine  is  rapidly  poured 
a  like  amount  of  concentrated  hydrochloric  acid  ;  at  the 
same  time  a  drop  of  fresh  concentrated  bleaching  powder 
is  added  (the  Ca(0Cl)2  may  be  placed  on  the  lip  of  the  tube 
containing  the  HCl  and  carried  with  the  latter  as  it  is 
poured  into  the  urine),  and  the  whole  mixed  together  by 
turning  up  the  test  tube.  If  now  10  to  12  drops  of  chloroform 
are  added,  the  indigo  blue  that  is  formed  if  indoxyl 
sulphate  is  present  is  dissolved. 

It  is  essential  that  too  much  hypochlorite  is  not  used, 
as  j;his  wJJl  (Convert  the  indigo  blue  into  yellow  isatin. 


EXAMINATION   AND   ANALYSIS   OF   URINE     417 

The  depth  of  the  blue  colour  imparted  to  the  chloroform 
provides  a  sufficient  index,  for  ordinary  purposes,  to  the 
amount  of  indican  present.  With  this  test  potassium 
iodide,  if  present  in  the  urine,  yields  a  deep  carmine  colour. 


III.    ABNORMAL  URINARY  CONSTITUENTS. 

I.  Bile  Pigments  and  Acids,  (a)  Bile  Pigments.  Bili- 
rubin, hydrobilirubin,  biliverdin,  etc.,  are  found  in  the 
urine  in  cases  of  jaundice,  though  it  is  probable  that  only 
bilirubin  is  present  in  freshly-voided  urine,  the  others  being 
formed  by  oxidation  after  standing. 

Gmehn's  test  is  sufficient  in  most  cases,  but  is  fallacious 
if  there  is  much  indican  present,  and  also  if  antipyrin  is 
being  taken  by  the  patient.  To  perform  this  test  run  about 
an  inch  of  urine  on  to  a  like  amount  of  crude  nitric  acid  in 
a  test  tube.  If  bilirubin  is  present  the  following  rings  of 
colour  will  be  seen  in  the  urine — from  above  downwards 
green,  blue,  violet,  red,  and  yellow.  The  green  ring  is 
the  most  important  and  is  sufficient  for  diagnosis. 

An  even  more  delicate  test  is  to  run  on  to  some  of  the 
urine,  acidified  with  acetic  acid,  a  layer  of  a  1  per  cent, 
solution  of  iodine  in  alcohol.  If  bile  is  present  a  green  ring 
occurs  in  less  than  a  minute. 

[b)  Bile  Acids.  These  are  often  present  in  the  urine 
of  jaundiced  persons,  and  may  be  tested  for  as  follows — 
Add  1  drop  of  1  per  cent,  watery  furfurol  to  1  cc. 
of  the  suspected  urine  and  super-impose  this  on  1  cc. 
of  concentrated  sulphuric  acid,  cooling  the  while  ;  a  red 
colour  is  formed  if  bile  acid  is  present,  which  deepens  in 
colour  on  standing. 

The  property  of  bile  salts  of  lowering  the  surface  tension 
of  fluids  is  utilised  in  Hay's  test,  which  is  said  to  be  positive 
in  so  weak  a  dilution  as  1  in  100,000.  The  test  is  very 
simple  : — Sprinkle  on  to  the  cooled  urine  a  little  finely- 
])owdered  sulphur,  if  this  sinks  in  one  minute  bile  salts 
are  present  in  the  ])roportion  of  I  :  40.000. 

II.  Proteids.  The  urine  may  contain  albumins,  globulins, 
albumoses,  or  uiuceiii.     Any  of  these  except  mucein  must 

M.D.  27 


418  MEDICAL   DIAGNOSIS 

be  regarded  as  pathological  until  they  have  been  thoroughly 
investigated  {vide  ii\Jra). 

Mucein  is  found  in  two  forms — an  insoluble  form,  which 
occurs  as  a  cloud  in  the  upper  layers  of  a  urine  that  has  been 
standing,  and  a  soluble  form,  which  is  precipitated  by  a 
drop  of  acetic  acid,  only  to  dissove  in  excess. 

It  has  no  special  significance,  but  an  excess  would  indicate 
a  catarrh  of  the  urinary  tract. 

Albumin.  The  presence  of  albumin  is  one  of  the  leading 
symptoms  of  nephritis  and  the  coincident  appearance  of 
casts  is  highly  suggestive  of  a  definite  renal  lesion. 

The  albumin  is  derived  from  the  serum  albumin  of  the 
blood,  and  the  fact  that  it  is  so  much  more  common  than 
serum  globulin  can  be  explained  by  its  much  smaller 
molecule.  For  a  similar  reason  fibrinogen  is  hardly  ever 
found  in  urine  ;  when  it  is  present  the  urine  solidifies  on 
standing. 

Clinical  Albuminuria  may  occur  in  the  following  circum- 
stances other  than  serious  organic  renal  change  :— 

(i.)  Contamination  from  vaginal  secretion  :  the  likeli- 
hood of  this  renders  imperative  the  catheterisation  of 
any  female  suspected  of  albuminuria.  Similarly  prostatic 
or  urethral  disease  must  be  considered  in  the  male. 

(ii.)  After  strenuous  muscular  endeavour  a  large 
percentage  of  athletes  have  a  transient  albuminuria.  This 
lasts  for  three  to  four  hours,  and  not  infrequently  is 
accompanied  by  a  few  granular  casts  and  red  blood  cells. 
Although  this  does  not  appear  to  lead  to  any  permanent 
renal  disability,  nevertheless  w^e  cannot  but  feel  that  for 
the  time  being  the  kidney  is  undoubtedly  in  a  pathological 
condition. 

A  similar  albuminuria  is  sometimes  seen  after  prolonged 
mental  strain  such  as  sitting  for  the  I.C.S.  examination, 
(iii.)  Cold   baths,   if    sufficiently   prolonged,    induce    a 
slight  and  transient  albuminuria. 

(iv.)  For  the  first  ten  days  of  life  albuminuria  is  common, 
(v.)  Pregnant    women    frequently    have    albuminuria 
during  the  latter  part  of  the  pregnancy. 

(vi.)  The  essential  albuminuria  of  Posner.  This  in- 
cludes : — 


EXAMINATION  AND  ANALYSIS   OF  URINE     419 

A.  Albuminuria  of  adolescence,  in  which  there  is 
apparently  a  slight  renal  insufficiency  at  puberty  and 
for  a  few  years  after,  but  which  disappears  completely 
as  maturity  proceeds. 

B.  Postural  albuminuria,  in  which  the  urine  is  free 
from  albumin  only  while  a  horizontal  position  is  main- 
tained. As  a  rule  no  other  evidence  of  disease  can  be 
discovered,  but  sometimes  there  will  be  a  movable 
kidney,  definite  neurasthenia,  etc.  ;  and  a  certain  pro- 
portion of  cases  of  progressive  nephritis  first  manifest 
themselves  in  this  way.  Granular  casts  are  present,  but 
in  very  scanty  numbers. 

C.  About  2  per  cent,  of  all  people  show  a  slight 
albuminuria.  When  this  is  not  evidence  of  commencing 
nephritis  it  oan  perhaps  be  considered  as  a  congenital 
abnormality  in  the  glomerular  or  tubal  epithelium, 
whereby  a  slightly  increased  amount  of  albumin  to 
the  normal  is  permitted  to  escape.  f 

All  urines  contain  a  minute  trace  of  albumin,  but 
not  sufficient  to  be  detected  by  the  ordinary  chemical 
tests. 

(vii.)  The  albuminuria  of  fevers  and  of  cardiac 
insufficiency.  These,  of  course,  are  pathological,  but, 
provided  the  cause  be  removed,  the  kidney  seems  to 
exhibit  perfect  recuperative  powers. 

In  conclusion  we  would  emphasise  the  fact  that  albu- 
minuria is  only  a  symptom  and  that  the  amount  of  albumin 
present  may  serve  as  an  idea  of  the  importance  of  the  renal 
lesion,  but  that  in  no  case  does  the  organism  suffer  directly 
from  the  loss  of  the  albumin  passed  in  the  urine. 

Tests  for  the  Presence  of  Albumin.  To  examine  urine 
for  albumin  it  is  best  to  test  samples  passed  at  different 
times  of  the  day  in  order  to  exclude  the  postural  or  cyclical 
forms  of  albuMiinuria,  but  if  only  one  examination  is  to  be 
made,  then  take  the  urine  passed  at  the  close  of  the  day's 
work  and  examine  it  as  fresh  as  possible.  If  the  urine  is 
cloudy  it  should  be  filtered,  and  if  concentrated  it  should  be 
diluted  until  its  specific  gravity  is  less  than  1,010,  for  albumin 
may  easily  be  missed  if  tlie  urine  is  of  very  high  specific 
gravity. 

27—2 


420  MEDICAL  DIAGNOSIS 

For  clinical  purposes  the  two  following  tests  are  sufficiently 
accurate,  and  both  should  be  performed,  each  as  a  control 
on  the  other  : — 

(i.)  Heat  and  Acetic  Acid.  Fill  a  test  tube  three-quarters 
full  with  the  filtered  and,  if  necessary,  diluted  urine  ;  hold 
the  tube  by  the  bottom  and  heat  the  upper  part  of  the  column 
of  urine  in  a  spirit  flame  (gas  flames  are  apt  to  form  a  conden- 
sation on  the  wall  of  the  tube). 

Albumin  is  precipitated  by  heat,  and  even  very  faint 
clouds  may  be  detected  if  the  tube  is  held  against  a  black 
background. 

Whether  there  is  a  precipitate  or  not,  2  or  3  drops  of 
20  per  cent,  acetic  acid  should  be  added  to  the  urine  after 
heating,  for  calcium  phosphate  and  calcium  carbonate 
are  both  precipitated  by  heat  as  well .  as  albumin.  If, 
however,  the  precipitate  is  albumin,  it  will  be  unchanged, 
or  even  increased,  by  the  acid,  whereas  the  phosphates 
and  carbonates  will  disappear,  the  latter  with  effervescence. 
Apart  from  this  it  is  essential  to  add  the  acid,  because  the 
original  urine  may  not  have  been  acid  enough  for  precipi- 
tation owing  to  the  presence  of  albumin  in  the  form  of  alkali- 
albumin,  and  no  cloud  may  appear  until  the  acetic  acid  is 
added. 

It  is  well  to  add  the  acid  drop  by  drop  and  to  boil  the  top 
of  the  urine  again  between  each  drop. 

Very  occasionally  the  urine  may  be  too  acid  to  permit 
the  precipitation  of  the  albumin  owing  to  the  presence 
of  albumin  in  the  form  of  acid-albumin ;  a  drop  of  caustic 
soda  should  then  be  added. 

On  no  account  should  too  much  acid  be  added,  as  soluble 
acid-albumin  may  be  produced.  Hence  it  is  not  always  pos- 
sible to  be  sure  that  a  cloud  formed  by  heat  which  disappears 
with  acid  is  due  to  phosphates  ;  but  the  minute  trace  of 
acid  necessary  to  remove  the  phosphates  makes  this  objection 
theoretical  rather  than  practical,  and  in  our  opinion  the 
above  test  is  the  best  of  all  for  the  estimation  of  the  presence 
of  albumin. 

Nucleo-albumin  will  be  thrown  down  by  the  above  test ; 
it  is,  however,  also  precipitated  by  acetic  acid  in  the  cold  : 
it  is  not  a  norma]  constituent  of  the  urine,  and  is  most  likely 


EXAMINATION  AND   ANALYSIS   OF  URINE     421 

to  occur  in  those  conditions  in  which  nucleo-proteid  proper 
is  present  as  well.  If  any  doubt  exists  on  this  point  Heller's 
test  {vide  infra)  will  settle  the  question. 

(ii.)  Heller  s  Test.  Place  about  1  inch  of  colourless 
concentrated  nitric  acid  into  a  test  tube  ;  run  gently  on  to 
this  from  a  pipette  a  like  amoinit  of  the  filtered  and  diluted 
urine,  being  very  careful  not  to  mix  the  two  fluids.  If 
there  is  albuminuria  a  white  ring  \\\\\  be  formed  at  the 
junction  of  the  urine  and  the  acid.  If  no  ring  has  formed 
within  three  minutes,  there  is  less  than  "003  per  cent, 
of  albumin. 

The  following  fallacies  must  be  borne  in  mind  : — 

A.  Urates.  These  will  be  precipitated  from  all  con- 
centrated urines  ;  the  ring,  however,  is  broader  than  the 
albumin  ring  and  is  well  above  the  line  of  contact.  It 
is  not  formed  in  diluted  urine  and  disappears  on  heating. 

B.  Urea  Nitrate.  This  is  a  solid  crystalline  crust 
and  should  not  cause  confusion.  It  does  not  form  in 
diluted  urine. 

C.  Nucleo- Albumin.  This  ring  is  rather  above  the 
line  of  contact,  is  slightly  opalescent,  and  is  dissolved 
on  shaking  the  tube  so  as  gently  to  mix  the  two  fluids. 

D.  Albumoses  are  precipitated  at  the  line  of  contact  ; 
they,  however,  disappear  on  heating. 

E.  Resinous  Acids,  in  those  who  are  taking  the  oleo- 
balsams,  give  a  dense  ring  which  partly  dissolves  on  warm- 
ing and  is  completely  soluble  in  excess  of  ether. 

Of  the  two  tests  just  described  the  heat  and  acetic  acid 
test  is  the  more  delicate,  but  both  should  be  performed  in 
each  case,  and  if  proper  care  in  the  technique  is  observed, 
there  is  little  chance  of  error. 

(iii.)  Quantitative  Determination  of  Albumin.  The  use  of 
Esbach's  tubes  is  sufficiently  reliable  for  most  clinical 
purposes,  though  really  there  is  a  very  large  margin  of  error. 
The  only  accurate  method  is  to  weigh  the  precipitate. 

In  using  Esbach's  method  four  essential  points  are  of 
))rime  importance  if  the  optimum  result  is  desired  : — 

{a)  Dilute  the  urine  till  its  specific  gravity  is  below 

1,008. 

(6)  Acidify  the  urine  with  acetic  acid. 


422  MEDICAL   DIAGNOSIS 

(c)  Always  perform  the  test  in  a  room  kept  at  approxi- 
mately the  same  temperature. 

(d)  If  the  reading  is  above  4  grms.  per  Utre,  do  the 
test  again  with  a  weaker  dilution  of  urine  until  the  reading 
is  less  than  this  amount.  Of  course  the  dilution  must 
be  allowed  for  in  the  final  calculation. 

To  perform  the  test.  Fill  one  of  the  tubes  up  to  the  mark 
U  with  the  properly  diluted  and  acidified  urine  and  then  add 
the  reagent  till  the  mai^k  R  is  reached  :  now  insert  the  cork 
and  invert  the  tube  three  or  four  times  (avoiding  shaking) 
till  the  fluids  are  mixed  ;  allow  the  tube  to  stand  for  exactly 
twenty-four  hours  in  a  constant  temperature  and  read  the 
height  of  the  precipitate  against  the  scale  on  the  tube. 
This  scale  is  marked  to  read  grammes  of  albumin  per 
litre.  The  original  dilution  of  the  urine  must  finally  be 
allowed  for.  , 

Serum  Globulin.  The  significance  of  an  increased  pro- 
portion of  globulin  to  albumin  in  nephritis  is  not  estabhshed  ; 
our  view  is  that  the  more  acute  the  lesion  the  larger  the 
proportion  of  globulin. 

Globulins  are  precipitated  by  the  addition  to  the  urine  of 
an  equal  amount  of  saturated  sulphate  solution. 

Since  they  are  also  insoluble  in  distilled  water,  a  cloud 
will  be  formed  if  a  few  drops  of  globulin-containing  urine 
be  thrown  into  a  beaker  of  distilled  water. 

Alfoumoses  may  be  found  in  the  urine  accompanying  the 
albumin  of  an  acute,  or  less  commonly  a  chronic,  tubal 
nephritis  ;  they  may  also  occur  when  there  is  resorption  of 
some  extensive  exudate,  as  in  pneumonia,  after  the  ingestion 
of  unusually  large  amounts  of  albumoses,  in  phosphorus 
poisoning,  in  gangrene,  in  cancer,  and  even  in  insanity. 
Albumosuria  is  thought  by  some  to  be  especially  common  in 
syphilitic  nephritis  and  to  be  induced  by  a  smaller  intake  of 
albumose  if  there  is  gastric  or  intestinal  ulceration. 

The  best  test  for  albumose  is  to  saturate  the  urine  with 
ammonium  sulphate,  when  a  flocculent  white  precipitate 
is  thrown  down.  The  urine  must  first  be  freed  from  albumin 
by  adding  an  excess  of  sodium  acetate  and  concentrated 
ferric  chloride,  neutralising  or  leaving  faintly  acid,  boiUng 
and,  finally,  filtering  (Hofmeister). 


EXAMINATION   AND   ANALYSIS   OF   URINE     423 

The  diagnostic  value  of  albumosuria  is  very  limited. 
Bence-Jones'  Body.     The  chemical  identity  of  this  body 
has  not  yet  finally  been  estabhshed  ;  it  is  closely  allied  to 
the  albumoses  and,  according  to  some  workers,  even  more 
nearly  related  to  albumin. 

The  occurrence  of  Bence-Jones'  proteid  in  the  urine  is  of 
the  utmost  rarity,  and  seems  practically  to  be  limited  to 
cases  of  multiple  myelomatosis. 

The  tests  for  this  body  are  as  foUows  : — 

(i.)  On  heating  the  acidified  urine  a  precipitate  is 
thrown  down  at  about  60°  C,  which  dissolves  when  a 
higher  temperature  is  reached. 

(ii.)  Heller's  test  with  nitric  acid  gives  a  yellowish  ring 
which  disappears  on  warming. 

(iii.)  In  common  with  the  true  albumoses,  a  Biuret 
reaction  (a  rose-pink  colour  with  a  trace  of  copper  sulphate 
and  excess  of  strong  caustic  potash)  can  be  obtained  by 
Bence-Jones'  body. 

III.  Blood  AND  ITS  Derivatives.  A.  Haematuria.  Blood 
in  the  urine  may  be  a  symptom  of  the  following  conditions  : — 

(i.)  Acute  nephritis,  whether  primary  or  following  the 
ingestion  of  such  poisons  as  turpentine  or  cantharides,  or 
chronic  hsemorrhagic  nephritis. 

(ii.)  New  growth  of  the  kidney,  ureter,  bladder,  prostate, 
or  urethra. 

(iii.)  Calculus  of  the  kidney,  bladder,  or  prostate. 

(iv.)  Tuberculosis  of  the  kidney  or  bladder. 

(v.)  Filaria,  bilharzia,  or  even  echinococcus. 

(vi.)  Infarction  of  the  kidney,  and  more  rarely  venous 
thrombosis. 

(vii.)  Haeraorrhagic  forms  of  the  exanthems,  especially 
scarlet  fever,  mea.sles,  small  pox,  enteric  fever. 

(viii.)  Purpura  (especially  Henoch's  purpura),  scurvy 
and  hsemophiha. 

(ix.)  Malaria. 

(x.)  Renal  epistaxis,  which  is  haemorrhage,  usually, 
from  one  kidney,  intermittent,  and  associated  with  no 
histological  lesion  in  those  cases  in  which  the  kidney  has 
been  removed. 

(xi.)  Pernicious  anaemia  and  leukaemia  (rare). 


424  MEDICAL   DIAGNOSIS 

(xii.)  Trauma,  as  from  faulty  catheterisation. 
If  the  blood  comes  from  the  kidney,  it  is  intimately  mixed 
with  the  urine  and  clots  are  unhkely  ;  if  from  the  bladder, 
the  urine  passed  at  the  end  of  micturition  contains  most 
blood,  and  clots  are  frequently  present.  Cystoscopy  should 
be  employed  to  determine  the  source  of  hsemorrliage  in 
doubtful  cases. 

If  the  colour  of  the  urine  is  not  conclusive  the  following 
tests  may  be  employed  to  demonstrate  the  presence  of  blood 
in  the  urine  : — 

(a)  The  Microscope.  If  the  urine  is  allowed  to  settle 
and  a  drop  of  the  deposit  examined  fresh  with  a  ^  inch 
objective,  the  red  blood  cells  will  at  once  be  seen.  The 
presence  of  white  cells  is  of  course  insufficient,  as  they 
may  be  pus  cells  or  on  the  way  to  become  such. 

(6)  The  Ouaiacum  and  Ozonic  Ether  Test.  If  necessary 
the  urine  is  acidified  with  acetic  acid  and  a  few  drops 
of  a  20  per  cent,  solution  of  guaicum  resin  in  alcohol  added  ; 
this  mixture  is  boiled  and  when  cool  overlaid  with  some 
ozonic  ether.  A  blue  colour  is  imparted  to  the  lower  part 
of  the  ozonic  ether  if  blood  is  present. 

This  test  is  extremely  delicate,  and  if  it  is  negative 
blood  may  be  assumed  to  be  absent.  Certain  other  organic 
substances  may  give  a  positive  reaction,  and  if  the  boiling 
is  omitted  pus  will  be  found  a  fruitful  source  of  error 
(cf.  p.  331,  "  Occult  Blood  Test  "). 

(c)  The  Spectroscope.  If  the  blood  is  fresh,  the 
spectrum  of  oxyhsemoglobin  will  be  obtained.  In 
nephritis,  however,  and  in  hsemoglobinuria  the  spectrum 
of  methaemoglobin  is  more  likely. 

B.  Hsemoglobinuria.  The  presence  of  haemoglobin  in  the 
urine  is  due  to  the  destruction  of  red  blood  cells  with  libera- 
tion of  haemoglobin.  It  may  occur  from  the  following 
causes  : — 

(i.)  Blackwater  fever  :  here  it  is  not  certain  whether 
it  is  the  result  of  malaria,  or  of  excessive  quinine,  or  both 
(w(?e  p.  131). 

(ii.)  Certain  poisonous  materials,  such  as  quinine, 
potassium  chlorate,  carbon-monoxide,  arsenuretted  hydro- 
genj  etc. 


EXAMINATION   AND   ANALYSIS   OF   URINE     425 

(iii.)  The  malignant  form  of  certain  exanthems,  as 
scarlet  fever. 

(iv.)  As  a  rare  manifestation  of  "  serum  sickness." 
(v.)  After  bums  or  prolonged  exposure  to  cold, 
(vi.)  As  a  vasometer  disturbance  associated  sometimes 
with  Raynaud's  disease. 

The  presence  of    haemoglobin  may  be  demonstrated  as 
follows  : — 

(a)  By  the  guaiacum  and  ozonic  ether  reaction  being 
positive  and  yet  no  blood  cells  being  shown  microscopi- 
cally. 

(6)  By  the  spectroscope.  A  spectrum,  sometimes 
mixed,  of  oxy-  reduced  and  methaemoglobin  is  obtained, 
but  usually  the  spectrum  of  methsemoglobin  predomi- 
nates. 

N.B.  If  bacteria  are  present  oxidation  will  result  in 

the  production  of  the  spectrum  of  pure  oxyha^moglobin. 

(c)  The  greenish-black  colour  of  the  urine.  / 

ly.    Pyuria.    Suppuration  anywhere  in  the  urinary  tract 

will  result  in  the  appearance  of  pus  in  the  urine  ;  but  a  few 

pus  cells  are  commonly  present  in  tubal  nephritis,  and,  of 

course,  whenever  blood  is  present  leucocytes  will  also  be 

found. 

Urine  which  contains  pus  is  usually  alkaline,  but  a  few 
bacilli,  such  as  Bacillus  tuberculosus,  BaciUus  coli  and  the 
gonococcus,  cause  pus  in  acid  urine.  If  an  equal  volume 
of  strong  caustic  potash  solution  is  added  to  urine  which 
contains  pus  a  sticky  gelatinous  mixture  results. 

Perhaps  the  simplest  test  for  pus  is  to  examine  micro- 
scopically some  of  the  deposit  after  centrifugalisation  ;  the 
pus  cells  will  readily  be  recognised,  though  any  nucleus 
may  be  unrecognisable  unless  acetic  acid  is  added.  The 
more  alkaline  the  urine  the  more  swollen  and  glassy  do 
the  pus  cells  appear. 

Both  ])us  and  blood  giv^e  positive  albumin  tests,  and  Posner 
has  estimated  that  1  per  cent,  of  albumin  is  produced  by 
50,000  leucocytes  per  cubic  centimetre  of  shaken  urine. 

Pus  cells  should  not  be  mistaken  for  e])itlu'lial  cells  ;  the 
different  shape  and  size  of  the  cells  and  the  different  appear- 
ance of    the  nucleus   (if  this  is  visible  it  is  usually  poly- 


426  MEDICAL   DIAGNOSIS 

morphous  in  pus  cells  and  is  not  vacuolated)  should  prevent 
mistake. 

V.  Glycosuria.  In  normal  urine  rather  more  than 
2  grms.  of  carbohydrate  are  excreted  daily  in  the  form  of 
glucose,  glycuronic  acid,  chondroitin-sulphuric  acid,  maltose, 
etc.  Every  individual  has  a  toleration  point  for  sugar 
ingestion  beyond  which  clinical  glycosuria  results.  As  an 
average  150  grms.  of  sugar  can  be  taken  without  an  appre- 
ciable amount  appearing  in  the  urine. 

In  certain  diseases,  notably  cirrhosis  of  the  liver  and 
acute  infectious  diseases,  the  toleration  point  is  low  ;  while 
at  all  times  milk-sugar  is  less  well  tolerated  than  dextrose 
or  cane-sugar. 

If  glycosuria  results  from  the  ingestion  of  starch  it  is 
probable  that  true  diabetes  is  present.  Temporary  glyco- 
suria in  cases  of  extreme  malnutrition  and  starvation 
is  common. 

Glycosuria  recognisable  by  the  ordinary  tests  is  the 
result  of  the  presence  of  more  than  '2  per  cent,  of  sugar 
in  the  blood. 

In  phloriclzin  diabetes,  but  in  no  other  case,  the  glycosuria 
occurs  with  a  hypo-glyceemia  (less  than  2  per  cent,  of  sugar 
in  the  circulating  blood),  and  is  caused  by  direct  injury 
of  the  renal  epithelium.  In  addition  to  phloridzin  and 
starvation  glycosuria,  sugar  may  occur  in  the  urine  in  the 
following  conditions  : — ■ 
(i.)  Diabetes  mellitus. 

(ii.)  Certain  head  injuries  or  diseases  of  the  brain 
(especially  in  the  neighbourhood  of  the  fourth  ven- 
tricle). 

(iii.)  Arterio-sclerosis  and  certain  affections  of  the  liver. 
(iv.)  After   the   ingestion   of   large   amounts   of   sugar 
or  starch. 

(v.)  In  pancreatitis. 
(vi.)  After  anaesthesia  by  chloroform, 
(vii.)  Certain  cases  of  disease  of  the  supra-renal  bodies 
associated  with  hypersecretion  of  adrenalin, 
(viii.)  A  few  cases  of  Exophthalmic  Goitre, 
(ix.)  Certain  cases  of  Hyper  pituitarism. 
(x.)  In  nursing  women  (Lactosuria). 


EXAMINATION  AND   ANALYSIS   OF    URINE     427 

The  presence  of  sugar  in  the  urine  may  be  shown  in  the 
following  ways  : — 

(1)  The  Reduction  of  Fehlina's  Solution}  It  is  essential 
to  use  freshly-prepared  Fehhng's  solution.  It  is  best 
therefore  to  mix  equal  volumes  of  FehUng  A  and  Fehhng 
B  in  a  test  tube  and  boil  ;  a  few  drops  of  urine  are 
then  added  and  the  mixture  brought  to  the  boil  again  ; 
if  sugar  is  present  to  the  amount  of  '3  per  cent,  a  yellowish- 
red  precipitate  of  cuprous  oxide  is  thrown  down. 

The  following  points  should  be  remembered  : — 

(a)  Never  add  more  urine  than  half  the  amount 
of  mixed  Fehling's  solution. 

(6)  Avoid  prolonged  boiling. 

(c)  Suspect  a  precipitate  that  only  appears  on 
standing. 

{d)  Remove  albumin  before  doing  the  test  if  more  than 
a  trace  is  present,  as  this  hinders  precipitation. 

(e)  Dilute  the  urine,  if  it  is  of  very  high  specific 
gravity,  tiU  the  specific  gravity  is  about  1,010. 

(/)  Remember  that  excess  of  urates  may  cause  a 
positive  reaction,  as  may  glycuronic  acid  compounds, 
pyrocatechin,  or  the  intake  of  the  following  drugs  : — 
Camphor,  chloroform,  chloral,  morphia,  phenol,  men- 
thol, salicylic  acid,  benzoic  acid,  rhubarb,  copaiba, 
sulphonal,  santonin,  etc.  These  fallacies  are  minimised 
by  dilution  of  the  urine. 

(2)  The  Fermentation  Test.  A  small  piece  of  yeast  is 
placed  in  the  urine,  which  is  then  gently  shaken  and  poured 
into  a  fermentation  tube. 

If  gas  is  formed  it  may  be  assumed  that  a  sugar  containing 
three  or  a  multiple  of  three  carbon  atoms  is  present. 

Two  controls  should  be  put  up,  one  of  a  urine  which  is 
known  to  contain  glucose  and  one  of  a  known  normal 
urine.  The  former  proves  that  the  yeast  is  active  and 
the  latter  that  there  is  not  auto -fermentation  of  the  yeast. 

(3)  The  Polariscope.  With  this  instrument  use  is 
made  of  the  fact  that  glucose  rotates  the  plane  of  polarised 
light  to  the  right.     Albumin  is  slightly  laevo-rotatory  and 

'  Fehling  A      Coppi^r   Sulphate,   34-639   gnus.;   Distilled    Water,  200  oo. 
Fehling  B  -  Eochelle  fcjalt,  173  grms.;  Caustic  Scxja  (14  per  cent.),  GOO  co. 


428  MEDICAL   DIAGNOSIS 

should  therefore  be  removed.     Glycuronic  acid  is  laevota- 
tory,  as,  of  course,  is  laevulose. 

If  cloudy  the  urine  should  be  cleared  by  filtration  after 
the  addition  of  lead  acetate. 

(Each  of  these  three  methods  is  of  value,  and  No.  2  or 
No.  3  may  well  be  used  as  controls  on  the  first.     From  a 
clinical  point  of  view  the  fermentation  test  is  easy,  free  from 
fallacy,  andtherefore  probably  the  best  for  the  practitioner.) 
(4)   Quantitative  Estimation  of  Sugar.     For  the  quanti- 
tative estimation  of  sugar  either  of  the  three  tests  already 
described  moiy  be  used,  but  with  none  is  it  very  easy  to 
ensure   great   accuracy.     If   a   precise   determination  be 
required  it  is  best  to  weigh  the  precipitate  thrown  down 
by  Fehling's  test  on  a  chemical  balance  after  drying. 
For  ordinary  purposes  it  is  enough  to  know  that  10  cc.  of 
Fehling's  solution  is  reduced  by  "05  grm.  of  dextrose  and  to 
discover  how  much  urine  (added  drop  by  drop  from  a  burette 
after  free  dilution)  is  required    to  decolorise  10  cc.  of    the 
boihng  solution.     From  this  the  calculation  of  the  sugar 
percentage  is  simple,  and,  if  the  amount  of  urine  passed  in 
the  twenty -four  hours  is  known,  the  daily  output  of  sugar 
can  be  estimated. 

Many  authorities  prefer  to  use  Pavy's  solution  ^  to  simple 
Fehling  for  the  quantitative  estimation  of  sugar  in  the 
urine.  The  advantage  is  that  the  presence  of  strong 
ammonia  prevents  the  formation  of  any  precipitate,  so  that 
the  end-point  of  the  reaction  is  indicated  by  the  disappear- 
ance of  the  blue  colour  from  the  solution.  It  is  important 
to  remember  that  10  cc.  of  Pavy's  solution  are  only  equal  to 
•005  grm.  of  glucose. 

To  estimate  the  amount  of  sugar  by  the  fermentation  test 
an  Einhorn  saccharometer  is  necessary.  A  piece  of  yeast 
the  size  of  a  bean  is  put  into  the  urine,  to  which  a  little 
tartaric  acid  has  been  added  to  prevent  alkalisation,  and  the 
saccharometer  filled  with  the  mixture.  This  is  allowed  to 
stand  for  twenty -four  hours  at  a  temperature  of  20°  to  40°  C. 

1  Pavy's  solution  =  Copper  sulphate  4"  158  grms. 
Rochelle  salt  20'4  grms. 
Caustic  potash  2 '4  grms 
Strong  ammonia  300  cc. 
Water  to  1,000  cc. 


EXAMINATION   AND   ANALYSIS   OF   URINE     429 

and  the  volume  of  gas  then  read  off  on  the  scale,  which  is  so 
graduated  as  to  read  the  equivalent  percentage  of  sugar. 

As  fermentation  proceeds  the  specific  gravity  of  the  urine 
becomes  lowered.  This  fact  can  be  utilis3d  to  give  a  rough 
idea  of  the  amount  of  sugar  present.  If  a  piece  of  yeast  is 
placed  in  a  jar  of  urine  and  the  jar  alloAved  to  stand  for 
twenty-four  hours,  then  each  degree  of  specific  gravity  lost 
by  the  urine  is  roughly  equivalent  to  2  per  cent,  of  glucose. 

The  amount  of  gas  evolved  depends  considerably  on  the 
activity  and  to  a  smaU  extent  on  the  amount  of  the  yeast 
used  ;  hence  this  method  is  not  conducive  to  great  accuracy. 

If  the  polarimeter  is  used  for  the  quantitative  estimation 
of  sugar  it  is  essential  to  clear  the  urine  and  to  free  it  from 
albumin.  The  instrument  is  filled  with  the  urine  and 
rotated  until  equal  illumination  is  observed  on  each  half  of 
the  field.  The  amount  of  rotation  is  now  read  on  the  scale 
and  the  amount  of  sugar  calculated  by  means  of  the  tables 
supphed  with  the  instrument.  Thus  a  100  per  cent.  S9lution 
of  glucose  has  a  rotatory  power  of  52*5°  to  the  right,  while 
Isevulose  of  similar  percentage  strength  rotates  the  plane  of 
the  light  through  93-8°  to  the  left. 

In  filling  the  urine  tube  care  must  be  taken  to  exclude  air 
bubbles. 

Normal  urine  is  slightly  Isevo-rotatory. 

VI.  Acetone  in  the  Urine.  This  body  is  present  in 
small  amounts  in  the  normal  urine ;  it  may  be  found  increased 
in  cases  of  ordinary  starvation,  during  the  treatment  (by 
starvation)  of  gastric  ulcer,  in  cases  of  cyclical  vomiting,  in 
the  terminal  stages  of  any  profound  cachexia,  in  auto -intoxi- 
cation, in  chloroform  poisoning,  and  especially  in  the  more 
advanced  stages  of  diabetes  melUtus,  when  there  is  insufficient 
alkali  circulating  to  neutralise  the  acid  products  of  abnormal 
metabolism  (probably  fat  metabolism).  Its  appearance 
in  the  urine  of  diabetics  possesses  therefore,  as  a  rule,  a 
certain  grave  significance.  It  imparts  to  the  urine  a  sweetish 
odour  as  of  apples,  and  this  smell  may  generally  be  observed 
in  the  breath  of  the  patient  at  the  same  time. 

In  the  case  of  diabetes  the  presence  of  acetone  is  scarcely 
so  iinj)ortant  as  the  presence  of  diacetic  acid,  since  if  diacetic 
acid  is  present  acetone  is  bound  to  be  there  also,  and  the  test 


430 


MEDICAL  DIAGNOSIS 


for  diacetic  acid  is  easy,  whereas  some  of  the  tests  for  acetone 
are  very  unsatisfactory  ;  further,   the   chnical  significance 
of  diacetic  acid  in  diabetes  is  greater  than  that  of  acetone. 
At  the  same  time  there  are  conditions  when  acetone  is 


Fia.  55. — Crystals  of  Ammonio-Magnesium  Phosphate. 
Magnification  X  216. 

present  and  in  which  diacetic  acid  is  not  found ;  therefore  a 
leHable  test  for  acetone  is  important. 

The  only  test  for  acetone  described  here  is  Rothera's  ;  it  is 
easy  of  apphcation,  accurate  and  free  from  fallacies. 

Rothera's  Test  (Garrod's  modification).  Add  5  cc.  of  a 
saturated  solution  of  ammonium  sulphate  to  5  cc.  of  the  urine ; 
next  add  3  drops  of  freshly-prepared  saturated  sodium 
nitro-prusside  solution,  and  lastly  add  2  cc.  of  ammonia. 


EXAMINATION  AND  ANALYSIS   OF  URINE     431 

Acetone  gives  a  slowly-developing  permanganate  colour 
which  is  quite  unmistakable  and  does  not  seem  to  be  given 
by  other  substances. 

VII.  DiACETic  Acid.  As  stated  above,  this  body  is  more 
important  than  acetone  and  is  produced  under  similar 
circumstances. 

It  is  readily  tested  for  by  Grerhardt's  test  : — Add  to  some 
of  the  suspected  urine  drop  by  drop  a  solution  of  ferric 
chloride  until  precipitation  ceases  ;  filter  and  add  to  the 
filtrate  a  few  more  drops  of  the  ferric  chloride  :  a  claret- 
coloured  solution  will  result  if  diacetic  acid  be  present. 

The  fallacies  in  this  test  are  that  the  colour  will  be  pro- 
duced by  sahcylates,  antipyrin,  and  a  iew  other  bodies  ; 
but  in  these  cases  the  colour  still  appears  after  boiling  the 
urine,  whereas  diacetic  acid  is  decomposed  and  evaporated 
by  boiling,  so  that  the  test  is  then  negative. 

VIII.  OxYBUTYRic  Acid.  Just  as  diacetic  acid  is  the 
parent  substance  of  acetone,  so  is  oxybutyric  acid  the  pre- 
cursor of  diacetic  acid.  Its  presence  is  hard  to  prove  because 
of  its  ready  dissociation  into  diacetic  acid  and  acetone,  but 
it  is  probably  the  all-important  factor  as  indicating  the 
onset  of  diabetic  coma. 

This  acid  is  laevo-rotatory,  and  its  presence  may  be  guessed 
at  if  the  urine  after  Jermentation  be  found  to  be  more 
definitely  Isevo-rotatory  than  normal  urine. 

IV.    URINARY  DEPOSITS. 

For  the  purpose  of  examining  urinary  deposits  it  is 
desirable  to  obtain  the  urine  as  fresh  as  possible,  while  a 
centrifuge  greatly  facilitates  the  work.  A  few  drops  of  the 
deposit  after  centriiugalisation  or  standing  in  a  conical  glass 
are  sucked  into  a  clean  pipette  and  expelled  from  this  on  to 
a  glass  slide.  A  cover-slip  may  now  be  superimposed  and  the 
preparation  examined  with  a  f  inch  and  \  inch  objective. 

Crystalline  Deposits. 

(i.)  Phosjihales  (Fig.  55).  The  white  deposit  of  phosphates 
dissolves  at  once  if  acid  is  added  ;  this  distinguishes  it  from 
pus.  Phosphates  are  only  deposited  in  alkaUne  or  very  weakly 
acid  urine.     Their  microscopical  appearances  are  variable, 


432 


MEDICAL   DIAGNOSIS 


but  the  most  usual  is  the  coffin-lid  or  pyramidal  shape  of 
ammonio -magnesium  phosphate  (triple  phosphates).  Cal- 
cium phosphate  is  of  more  rare  occurrence,  and  is  usually 
composed  of  wedge-shape  masses  radiating  in  all  directions 
from  a  common  centre. 

(ii.)  Oxalates  (Fig.  56).  The  clinical  significance  of  oxaluria 


D 


Fig.  56. — Crystals  of  Oxalate  of  Lime.     Magnification  x  216. 

is  very  doubtful,  but  in  so  far  as  calcium  oxalate  is  an 
important  factor  in  renal  calculi  the  persistent  and  excessive 
appearance  of  these  crystals  in  the  urine  may  be  of  some 
importance.  An  excessive  number  of  these  crystals  may 
also  give  rise  to  a  slight  albuminuria.  Their  frequency  in 
neurasthenia  is  suggestive. 


EXAMINATION   AND    ANALYSIS   OF   URINE     433 

Oxalate  crystals  may  be  found  in  both  acid  and  alkaline 
urine  ;  their  usual  shape  is  that  of  definite  octahedra 
(envelope  shape),  but  they  are  often  seen  as  spheres  or 
ovals,  either  grooved  or  showing  radial  striations. 

(iii.)  Sulphates  are  only  precipitated  from  very  acid 
urines  ;  they  usually  take  the  form  of  clusters  of  thin  needles 
or  tablets. 

(iv.)  Cystin  (Fig.  57).    Cystinuria  is  a  rare  familial  condition 


Fio.  57.— Crystals  of  Cystin.     Magnification  X  216. 

and  does  not  appear  to  be  of  pathological  import.  The  crys- 
tals are  beautiful  hexagonal  plates. 

(v.)  Clwlesterin  (Fig.  58)  is  but  rarely  found  in  the  urine, 
though  it  has  been  noted  in  cases  of  chronic  catarrhal 
cystitis.  The  characteristic  appearance  is  that  of  flat,  square 
or  oblong  crystals  with  one  corner  chipped  out. 

(vi.)  Uric  Acid  (Fig.  59).  These  crystals  are  recognised 
by  their  yellowish-bro^v^l  colour.  Their  most  usual  shape 
is  that  of  whetstones,  from  disappearance  of  the  corners  of 

M.D.  ^28 


434  MEDICAL   DIAGNOSIS 

the  original  rhombic  forms.  They  may  also  look  like  barrels 
or  needles,  and  sometimes  greatly  resemble  cystin. 

(vii.)  Urates  (Fig.  60)  are  not  usually  crystalline  in  appear- 
ance, being  an  amorphous  mass.  The  fact  that  they  disappear 
with  heat  serves  for  their  ready  recognition.  They  settle 
as  a  pink  mass  when  the  urine  cools,  but  in  the  urine  of 
children  they  are  usually  white. 

(viii.)  Leucinand  Tyrosin  (Fig.  61)  are  practically  diagnostic 


Fig.  58.— Crystals  of  Cholesterin.     Magnification  X  216. 

of   either    acute  yellow  atrophy  or  phosphorus  poisoning. 

When  present   leucin    consists  of  small,  clear-cut  spheres, 

while  tyrosin  is  likened  to  sheaves  of  wheat. 

Non-Crystalline    Deposits,     (i.)    Cells.     Three    types  of 

cells  may  be  found  in  urine  : — 

(a)  Epithelial  Cells.  Renal  epithelium  cannot  with 
certainty  be  distinguished  from  bladder  epithelium, 
though  the  kidney  cells  are  cubical  and  tend  to  show 
a  tail-hke  process  at  one  end,  while  the  bladder  cells  are 
larger,    more    flattened,    and    of    more    irregular    shape. 


^ 


^^ 


'^i^ 

^ 


C 


^ 


k 


Fig.  59.— Crystals  of  Trie  Arid      Mamiilication        210. 


•^ 


1^ 


#!•»>     ^ 

^^^ 


0^» 


V. 


% 


^ 


^ 


* 


Fri.  ti(t.     Crystals  of   .Vmmnniiiiii  I'nilr.      .Mai.'iiitii-ati<iM        2H't. 


EXAMINATION   AND   ANALYSIS   OF   URINE     435 

The  nuclei  of  kidney  cells  are  large  and  vesicular,  while 
those  of  bladder  cells  are  small  and  highly  refractile. 

Urethral  cells  are  cylindrical  or  transitional.  Squamous 
cells  indicate  a  vaginal  or  preputial  origin. 

(6)  Red  Blood  Cells.  Red  blood  cells  indicate  hsema- 
turia,  the  causes  of  which  have  been  considered  on  p.  432. 


Fig.  61.  — Crystals  of  J.oucin  and  Tyrosin.     Magnification  X  216 


(c)  While  Blood  Cells  may  be  present  in  their  normal 
proportions  to  red  blood  cells  in  cases  of  hsematuria  ; 
when,  however,  polymorphonuclear  leucocytes  are 
present  in  excess  or  without  red  blood  cells  they  indicate 
pyuria.  This  may  be  produced  by  suppuration  in  any 
part   of   the   urinary   tract.     Under   such   circumstances 

28—2 


436  MEDICAL   DIAGNOSIS 

a  bacteriological  examination  is  often  advisable  to  clear 

up  the  diagnosis. 

(ii.)  Casts  (Figs.  62  and  63).  It  is  customary  to  think  that 
the  presence  of  casts  in  the  urine  necessarily  indicates  a  true 
nephritis  ;  this  is  not  so,  for  casts  may  occur  in  any  of  the 
"  so-called  "  physiological  albuminurias,  and  even,  when 
there  is  no  albumin  at  all,  in  the  urine  of  presumably  healthy 


Fig.  62. — Eiiithclial  and  Fatty  Casts.     Magnification  X  216. 

persons.  Hence  it  is  probable  that  casts  need  only  mean  a 
temporary  functional  impairment  of  renal  epithelium.  Their 
continued  presence,  however,  should  certainly  excite  sus- 
picion, especially  if  other  signs  of  nephritis  are  present. 

As  a  general  rule  it  may  be  stated  that  the  persistence 
of  casts  after  the  albumin  has  disappeared  is  suggestive  of 


EXAMINATION   AND   ANALYSIS   OF   URINE     437 

a  granular  kidney,  while  the  converse  obtains  in  cases  of 
parenchymatous  inflammation. 

In   searching  for   casts  the   urine   should  be   examined 
immediately  after   it  is  passed,  for  casts  readily  disappear 


# 


# 


,/<f,  •■■■'■■'     ^  "■       j^r 


Fig   03.— Waxy  Casts.     Magnification  X  216. 

if  the  urine  is  allowed  to  stand  for  even  a  few  hours  before 
examination. 

The  procedure  is  the  same  as  for  all  other  urinary  deposits, 
and  no  stain  is  necessary. 

A  cast,  as  its  name  implies,  is  a  mould  of  part  of  a  urinary 
tubule  ;  as  a  rule  comparatively  short  lengths  only  are 
to  be  seen.  They  are  cylindrical  masses  the  length  of  which 
is  perhaps  from  three  to  six  times  their  breadth.     The  surface 


438  MEDICAL   DIAGNOSIS 

varies  with  the  nature  of  the  cast.     The  following  types 

are  described  : — 

(«)  Epithelial  Casts.  These  are  formed  of  renal  epithe- 
lium, probably  shed  piece-meal  and  passed  en  masse, 
though  occasionally  the  epithelium  of  a  length  of  tubule 
may  be  shed  as  a  whole.  The  individual  cells  may  be  well 
preserved  or  in  any  stage  of  degeneration. 

(6)  Fatty  Casts.  These  are  epithelial  casts  the  cells 
of  which  have  undergone  such  extensive  fatty  metamor- 
phosis as  to  leave  no  cell-bodies  to  be  distinguished  apart 
from  the  numerous  fatty  globules. 

(c)  Granular  Casts.  In  these  the  epithelial  cells  have 
undergone  granular  degeneration. 

(d)  Blood  Casts  are  suggestive  of  acute  nephritis  or  of 
trauma  to  the  kidney  ;  they  are  formed  by  the  effusion 
of  blood  into  the  renal  tubules. 

(e)  Hyaline  Casts.  These  are  pale,  structureless  casts 
of  a  very  regular  shape  and  loiv  refractive  index  ;  they  are 
not  necessarily  indicative  of  any  severe  pathological 
change  and  must  not  be  confused  with  the  following. 

(/)  Waxy  Casts.  These  are  highly  refractile,  whitish, 
dense-looking  casts,  sometimes  without  structure,  some- 
times finely  granular,  and  sometimes  tending  to  split 
transversely. 

They  occur  in  acute  or  chronic  nephritis,  just  as  do 
epithelial,  fatty,  and  granular  casts. 

The  term  "  waxy  "  has  no  connection  with  lardaceous 

disease  when  applied  to  urinary  casts. 

Casts   are   most   numerous   in   chronic   parenchymatous 

nephritis,  then  in  acute  tubal  nephritis,  and  fewest  in  chronic 

interstitial  nephritis.     The  better  the  preservation  of  the 

epithelium  forming  a  cast  the  more  acute  is  the  nephritis. 

It  is  not  easy  to  mistake  any  other  structure  for  casts, 
but  it  is  as  well  to  mention  the  following  possibilities  : — 

(1)  Cylindroids :  these  are  long,  tapering,  mucinous 
threads.  Casts  are  much  shorter  than  cylindroids  and 
have  blunt  extremities. 

(2)  Fragments  of  Thread,  Wool,  Linen,  etc.  :  these 
should  not  be  present  unless  the  vessel  used  for  receiving 
the  urine  is  dried  with  a  duster.     The  student  is  advised 


EXAMINATION   AND   ANALYSIS   OF   URINE     439 

to  familiarise  himself  with  the  microscopical  appearances 
of  such  foreign  bodies. 


V.    THE  BACTERIOLOGICAL  EXAMINATION    OF 
THE  URINE. 

For  this  purpose  catheter  specimens  of  urine  should  be 
received  into  sterile  vessels  and  examined  as  soon  as 
possible.  The  urine  should  be  examined  directly,  and 
cultures  should  also  be  made. 

For  the  direct  examination  the  urine  may  be  diluted  with 
an  equal  volume  of  alcohol,  in  order  to  lower  its  specific 
gravity  and  favour  the  deposit  of  the  bacilli  on  centrifugahsa- 
tion.  After  centrifuging  the  tube  is  rapidly  inverted  and 
emptied  :  a  portion  of  the  deposit  is  now  transferred  with 
a  platinum  loop  to  a  sterile  clean  glass  slide  and  spread  into 
an  even  fihn  ;  this  is  allowed  to  dry  in  the  air  and  fixed  by 
passage  through  a  Bunsen  flame. 

Some  authorities  advise  that  a  drop  of  egg  albumin  be 
first  placed  on  the  slide,  and  this  certainly  prevents  the  loss 
of  the  film  when  it  is  washed.  For  ordinary  purposes 
Loffler's  methylene  blue  is  the  best  stain  ;  it  should  be  used 
cold  and  allowed  to  act  for  seven  to  ten  minutes  :  the  film 
is  then  well  washed  in  tap-water,  dried  between  filtre  paper, 
and  examined  directly  with  an  oil  immersion  lens. 

It  is  well  to  make  a  second  preparation  stained  by  the 
method  of  Gram,  and  of  course,  if  tuberculosis  is  suspected, 
carbol-fuchsin  must  be  used,  as  described  on  p.  81, 

The  great  value  of  a  film  examination  lies  first  in  the  fact 
that  it  is  the  only  method  of  quickly  demonstrating  the 
tubercle  bacillus,  and  secondly  that  the  morphological 
appearances  of  any  bacilli  that  are  present  afford  valuable 
information  as  to  the  proper  culture  media  to  employ  for 
tlieir  further  investigation. 

Thus  diplococci,  such  as  gonococci  or  pneumococci,  grow 
best  on  fresh  blood-agar  :  the  Bacillus  coli  and  Bacillus 
typhosus  grow  well  on  ordinary  nutrient  agar,  but  may  be 
differentiated  by  cultures  in  some  such  medium  as 
McConkey's  bile-salt-litmus-glucose  solution.    Staphylococci 


440  MEDICAL   DIAGNOSIS 

should  be  planted  on  nutrient  agar,  while  streptococci  may 
be  cultivated  in  broth.  If  no  clue  as  to  the  identity  of  the 
organism  can  be  gathered  from  the  film  examination,  the 
best  medium  to  use  is  blood-agar  ;  the  colonies  should  be 
examined  as  they  appear  and  subcultures  made  on  appro- 
priate media. 

If  tubercle  bacilli  are  suspected  but  cannot  be  seen,  some 
of  the  centrifugalised  deposit  may  be  injected  into  a  guinea- 
pig,  as  described  on  p.  81. 

The  smegma  bacillus  possesses  very  similar  staining 
reactions  to  the  tubercle  bacillus,  except  that  it  is  more 
liable  to  decolorisation  with  alcohol  than  the  latter.  It 
should,  however,  be  excluded  if  the  utmost  care  and  clean- 
liness are  used  in  passing  the  catheter  for  the  obtaining  of 
the  specimen. 

In  an  ordinary  alkaline  cystitis,  such  as  occurs  behind  a 
stricture  of  the  urethra,  in  cases  of  paralysis  and  after 
repeated  catheterisations,  many  organisms  may  be  met  with, 
such  as  staphylo-  and  strepto-  cocci  and  various  forms  of 
bacillus. 

If  the  urine  is  acid  and  yet  contains  bacilli,  the  Bacillus 
coli  is  the  most  probable  organism,  but  the  gonococcus, 
Bacillus  typhosus,  and  the  tubercle  bacillus  are  also  found 
in  acid  urine.  The  Bacillus  coli  may  occur  in  large  numbers 
in  the  urine  without  the  presence  of  pus  ;  it  often  persists  for 
many  years  after  a  pyelitis  has  quieted  down.  The  tubercle 
bacillus  and  many  other  organisms  also  may  occur  without 
pus  when  there  is  a  blood  infection  by  the  particular  organism 
concerned  :  typhoid  fever  is  a  striking  example  of  this 
fact. 

The  only  parasites  of  importance  in  connection  Avith  the 
urine  are  the  following  : — 

(i.)  Bilharzia  haematobium,  which,  in  countries  where  it  is 
endemic,  is  responsible  for  many  cases  of  hsematuria.  The 
eggs  of  this  creature  are  passed  in  the  urine  and  may  be 
recognised  in  the  sediment  as  small  oval  eggs  *16  mm.  in 
diameter,  containing  an  indefinite  embryo  which  is  just 
visible  through  a  transparent  shell.  Each  egg  has  a  spinous 
process  at  one  end  of  it  {vide  p.  149). 

(ii.)  Echinococcus.     Hydatid  cysts  are  rare  in  connection 


EXAMINATION   AND   ANALYSIS   OF   URINE     441 

with  the  kidney.     Hooklets  and  scolices  may  sometimes  be 
found  in  the  urine  {vide  p.  142). 

(iii.)  Filaria  Sanguinis  Hominum  may  cause  chyluria  and 
the  embryos  may  be  discovered  in  the  chylous  urine  {vide 
p.  147). 


CHAPTER    III 


DISEASES   OF    THE  KIDNEY  AND   URINARY  APPARATUS 


I.    NEPHRITIS. 

The  etiology  of  nephritis  is  still  a  matter  of  extreme 
obscurity,  and  until  more  accurate  knowledge  has  been 
acquired  of  this  most  important  subject  it  is  best  to  adhere 
to  the  older  classifications,  which  were  based  primarily 
on  the  morbid  anatomy  and  histology  of  kidneys  as  seen 
in  the  post-mortem  room.  The  affections  are  described 
as  being  either  acute  or  chronic,  and  they  are  also  dis- 
tinguished according  as  to  whether  the  morbid  process 
has  principally  involved  the  renal  parenchyma  or  the  inter- 
stitial tissue.  As  a  worldng  basis  the  following  table  may  be 
employed.  Its  limitations  are  many,  for  in  all  cases  of 
nephritis  both  parenchymatous  and  interstitial  tissue  are 
involved,  and  therefore  a  clear-cut-type  case  is  the  exception 
rather  than  the  rule. 


Acute 
Nephritis 


Chronic 
Nephritis 


(I)  Parenchymatous    Acute  Tubal  Nephritis. 

f  {a)  Acute  Glomerular  Ne- 
phritis (scarlatinal). 
(6)  Acute     Pyelonephritis 
from     an     ascending 
infection  of  the  blad- 
l  der  (Surgical  Kidney). 

Chronic  Paren-  f  {a)  Large  White  Kidney, 
chymatous  Ne-  \  {b)  Large  Mottled  Kidney 
phritis  I  (hsemorrhagic). 

f  (a)  Red  Granular  Kidney. 
(6)  Arterio -sclerotic    KLid- 


(2)  Interstitial 


f(i) 


(2)  Chronic      Inter- 
stitial Nephritis 


L 


(c) 


ney. 

White 

ney.^ 


Granular   Kid- 


'  Since  there  is  so  pronounced  an  involvement  of  the  parenchyma  in  the 
white  granular  kidney,  it  might  with  equal  force  be  included  in  the  group  of 
chronic  parenchymatous  nephritis. 


DISEASES   OF   THE   KIDNEY,   ETC.  443 

A.  Acute  Tubal  Nephritis.  This  may  occur  during  any 
specific  infective  disease,  such  as  enteric  fever  or  pneu- 
monia, but  it  is  commonly  seen  after  a  simple  chill  or 
exposure  to  wet.  Another  fertile  cause  is  the  ingestion  of 
irritants,  such  as  cantharides  or  turpentine.  The  disease 
may  start  suddenly,  but  an  insidious  onset  is  more  common. 
There  may  be  malaise  and  headache  as  well  as  an  aching 
pain  in  the  loins,  but  quite  often  these  are  absent,  and  the 
first  thing  noticed  is  puffiness  of  the  face,  hands  and  feet, 
or  even  of  the  whole  body.  In  some  cases  haematuria,  in 
others  ursemic  convulsions,  may  be  the  first  sign.  The 
temperature  may  be  slightly  raised  at  the  outset,  but  it 
is  often  normal  throughout.  There  is  often  some  frequency 
of  micturition  at  the  outset,  but  the  total  amount  of  urine 
passed  is  diminished  until  convalescence  is  established,  when 
there  will  be  polyuria,  which  often  persists  for  a  consider- 
able time.  The  urine  contains  blood,  albumin,  and  casts 
(epithehal,  granular,  blood,  and  hyaline).  The  amount  of 
urea  is  markedly  diminished.  The  reaction  is  usually  acid, 
unless  a  very  large  amount  of  blood  is  present  and  the 
specific  gravity  slightly  raised,  so  long  as  albumin  is 
abundant. 

The  blood  pressure  is  moderately  raised  (140  to  160  mm. 
in  an  adult)  and  the  aortic  second  sound  is  accentuated. 

As  the  disease  advances  there  is  noticeable  anaemia. 

The  following  may  be  considered  complications  of  acute 
nephritis  : — 

(i.)  Retinal  Hcemorrhages.     These  are  rare,  especially 

when   compared   with   the   frequency   with   which   they 

occur  in  chronic  forms  of  nephritis. 

(ii.)  Amaurosis,  either  with  or  without  retinal  oedema. 

The  prognosis  is  good  as  regards  recovery  of  the  vision  if 

the  renal  mischief  is  checked. 

(iii.)  Suppression  of  Urine.     This  rarely  lasts  for  more 

than   thirty-six   to   forty-eight   hours   provided   suitable 

treatment   (hot-air  baths,   warm  packs,   diaphoretics)  is 

emploj'ed,  but,  if  persistent,  death  occurs  towards  the 

middle    of    the    second    week    from    so-called    "  latent 

unemia." 

(iv.)  Serous    Effusions.     These    nuiy    form    with    the 


444  MEDICAL   DIAGNOSIS 

utmost  rapidity  ;    hence  a  thorough  daily  examination 

is  essential. 

(v.)  (Edema  of  the  Glottis  may  occur  in  association  with 

general  anasarca  or  as  a  separate  complication.     Trache- 
otomy may  be  necessary. 

(vi.)  Pericarditis  is  often  a  terminal  event,  but  is  more 

common  in  chronic  nephritis, 
(vii.)  Cardiac  Dilatation. 
(viii.)  Bronchitis. 
(ix.)   Urcemia  {vide  special  section,  p.  458). 

B.  Acute  Glomerular  Nephritis.  The  description  given 
above  of  acute  tubal  nejjhritis  applies  with  equal  force  to 
the  variety  now  under  consideration,  but  scarlet  fever  is 
particularly  prone  to  be  complicated  by  an  acute  nephritis 
which  primarily  affects  the  glomerular  apparatus. 

The  mortality  of  post-scarlatinal  nephritis  is  high  (20  to 
30  per  cent.).  In  other  forms  of  acute  nephritis  the  mortality 
seems  to  depend  very  largely  on  whether  there  is  any  pre- 
existing kidney  lesion. 

It  should  never  be  forgotten  that  acute  or  sub -acute 
exacerbations  are  especially  Uable  to  occur  in  kidneys 
already  damaged  by  chronic  tubal  or  interstitial  change, 
and  in  these  the  outlook  is  correspondingly  grave. 

Every  effort  should  therefore  be  made  to  discover  whether 
the  kidneys  were  healthy  previous  to  a  particular  attack. 
For  this  purpose  the  history  is  most  important,  but  much 
can  be  learned  by  examination  of  the  heart  and  blood- 
vessels, for  all  chronic  renal  inflammations  are  inevitably 
accompanied  by  cardiac  hypertrophy  and  increased  blood 
pressure,  greater  than  can  be  explained  by  a  first  attack 
of  acute  nephritis.  The  fundus  oculi  should  also  be  examined 
for  haemorrhages,  old  or  recent,  for  the  more  chronic  the 
lesion  the  greater  the  likelihood  of  these  being  present. 

The  diagnosis  of  Acute  Nephritis,  whether  tubal  or 
glomerular,  does  not  present  many  difficulties  ;  the  following 
sources  of  error  may,  however,  be  mentioned  : — 

(i.)  The  albuminuria  of  acute  febrile  conditions,  especially 
of  diphtheria. 

(ii.)  The  albuminuria  of  chronic  heart  disease  which  is 
the  result  of  passive  congestion  of  the  kidneys. 


DISEASES   OF   THE   KIDNEY,   ETC.  445 

(iii.)  Infarction  of  the  Kidneys.  An  examination  of 
the  heart  wall  reveal  some  lesion  of  the  mitral  or  aortic 
valves,  whilst  the  hsematuria  is  not  accompanied  by  renal 
oedema  and  is  often  preceded  by  a  sharp  pain  in  one  or 
other  loin. 

(iv.)  Lardaceous  Disease.  The  presence  of  some  possible 
focus,  such  as  tuberculosis  or  sepsis,  together  with  a  low 
blood  pressure  and  probably  an  enlarged  liver  and  spleen, 
will  suggest  the  true  diagnosis. 

(vi.)  Renal  Epistaxis.  Here  there  is  no  oedema  or  cardiac 
hypertrophy,  and  cystoscopy  mil  show  that  the  blood  is 
coming  from  only  one  ureter. 

C.  Acute  Pyelonephritis.  Chronic  pyuria  and  cystitis 
(usually  alkahne),  together  with  an  enlarged  prostate  or 
an  old  urethral  stricture  or  paraplegia  from  any  cause,  Avill 
suggest  the  possibility  of  the  infection,  sooner  or  later, 
extending  up  the  ureters  to  the  kidneys.  For  a  long  time 
there  may  be  no  indication  that  this  has  happened,  but 
eventually  a  fatal  uraemia  will  develop  (vide  p.  458). 

D.  Large  White  Kidney.  In  some  cases  this  condition 
may  directly  follow  an  attack  of  acute  nephritis,  especially 
scarlatinal  nephritis.  More  often,  we  feel  convinced, 
it  arises  quite  independently  and  for  no  known  cause. 
It  progresses  steadily  to  its  appointed  end,  which  is  death. 
This  is  not  often  delayed  for  more  than  a  year  from  the 
onset  of  symptoms,  though  this  does  not  imply  that  there 
may  not  have  been  a  much  longer  course  before  symptoms 
developed. 

In  the  main  the  symptoms  and  signs  are  the  same  as  in 
acute  nephritis — headache,  nausea,  anaemia,  oedema,  and 
serous  effusions.  The  large  white  face  of  the  patient 
with  a  large  white  kidney  has  become  an  aphorism.  There  is 
more  cardiac  hypertrophy  and  a  higher  blood  pressure  than 
in  acute  nephritis,  but  neither  need  be  extreme.  The  urine 
is  scanty,  and  does  not  contain  blood  unless  a  subacute 
attack  is  superadded  to  the  chronic  affection.  The  urea 
is  diminished  and  albumin  is  copious  ;  casts  are  always 
present,  especially  the  epithehal,  fatty,  and  waxy  varieties. 
The  specific  gravity  is  high  unless  the  albumin  is  removed, 
when  it  is  low  owing  to  the  diminution  in  total  solids. 


446  MEDICAL   DIAGNOSIS 

The  complications  are  the  same  as  for  acute  nephritis, 
and  ura?mia  is  the  inevitable  conclusion  unless  some  inter- 
current malady,  such  as  bronchitis  or  pulmonary  oedema, 
proves  fatal  first 

E.  Chronic  Haemorrhagic  Nephritis  (Large  Mottled 
Kidney).  The  etiology,  course,  and  prognosis  of  this 
variety  are  the  same  as  in  large  white  kidney.  There 
would  seem  to  be  a  greater  tendency  to  haematuria  and 
haemorrhages  beneath  the  skin  and  from  the  mucous  mem- 
branes, and,  post  mortem,  the  appearances  suggest  a 
blend  of  acute  and  chronic  tubal  change.  Possibly  this 
variety  is  merely  a  large  white  kidney  in  which  the 
acute  exacerbations  follow  each  other  with  unusual 
frequency. 

F.  Red  Granular  Kidney.  Here  we  must  pre-suppose 
the  long-continued  action  of  certain  poisons  or  toxins 
which  exercise  a  selective  action  on  the  renal  arterial 
system  causing  a  gradual  peri -arterial  fibrous  tissue  replace- 
ment and  overgrowth.  The  effect  of  this  is  to  diminish 
the  area  of  functional  renal  tissue,  with  the  result  that  it  is 
necessary  to  force  more  blood  than  normal  through  the 
kidneys  in  order  to  maintain  the  proper  elimination  of  the 
waste  products  of  metabolism.  Hence  there  will  be  a 
secondary  and  compensatory  cardiac  hypertrophy  to  meet 
the  increased  demand  on  the  circulatory  apparatus.  The 
result  will  be  a  raised  blood  pressure  and  progressive  arterial 
degeneration  when  the  limit  of  hypertrophy  of  the  tunica 
media  has  been  reached.  In  like  manner  the  heart  muscle 
will  in  time  become  the  seat  of  fibrous  transformation  and 
cardiac  dilatation  will  ensue. 

The  toxins  responsible  for  the  inception  of  this  vicious 
circle  have  not  been  identified,  but,  be  that  as  it  may, 
red  granular  kidney  is  predisposed  to  by  gout,  syphilis 
(here  heredity  must  play  a  part),  long-continued  strain, 
both  mental  and  physical,  high  living,  alcohol,  sexual 
excesses,  lead  poisoning,  and  the  like. 

If  the  clinical  evidence  of  parenchymatous  nephritis  is 
fairly  obvious  the  opposite  is  true  of  the  red  granular 
kidney,  which  is  so  insidious  in  its  onset  and  progress 
as  often  to  be  unsuspected  until  its  last  phases,  or  even 


DISEASES   OF   THE   KIDNEY,    ETC.  447 

until  the  autopsy.     Attention  may  be  drawn  to  the  kidneys 
in  the  following  ways  : — 

(i.)  Symptoms    immediately  referable    to    the    cardio- 
vascular system   may  develop  and  the  hypertrophy  of 
the  heart  will  cause  suspicion  to  fall  on  the  kidneys, 
(ii.)  An  attack  of  subacute  or  acute  nephritis  may  occur, 
(iii.)  The  onset  of  ursemic  symptoms  may  be  the  first 
sign. 

Not  infrequently  patients  with  red  granular  kidneys 
enjoy  extremely  good  health  till  an  advanced  age  and  are 
able  to  lead  active  and  vigorous  lives. 

Those  patients  who  seek  advice  are  likely  to  be  over  40 
years  of  age  and  to  complain  of  increasing  muscular  weak- 
ness, with  dyspnoea  on  exertion  (often  paroxysmal  in 
type),  headaches,  noises  in  the  head,  insomnia,  gastro- 
intestinal disturbances,  and,  more  rarely,  failing  vision. 
Inquiry  will  elicit  the  fact  that  the  urinary  output  is  increased 
and  that  there  is  frequency  of  micturition,  especially  at  night. 
The  urine  is  pale,  clear  and  of  low  specific  gravity  (1,003 
to  1,012);  sometimes  there  is  a  trace  of  albumin,  but  more 
often  there  is  not,  and  from  time  to  time  a  few  granular 
casts  are  to  be  found.  The  urea  output  is  diminished. 
The  left  ventricle  of  the  heart  is  hypertrophied,  the  impulse 
is  diffuse  and  heaving,  and  the  aortic  second  sound  is 
accentuated.  The  blood  pressure  is  high  (160  to  220  mm. 
of  mercury)  and  the  arteries  are  thickened  and  often  tortuous. 
There  is  often  a  noticeable  anaemia.  Pigmentation  of 
the  skin  may  be  so  extreme  as  to  simulate  Addison's  Disease. 
The  ophthalmoscope  may  show  old  or  recent  haemorrhages, 
and  in  this  connection  it  must  be  remembered  that  other 
haemorrhages,  such  as  cerebral  haemorrhage,  petecchiae, 
or  melaena,  are  far  from  rare. 

Oedema  is  conspicuous  by  its  absence  unless  heart  failure 
with  dilatation  and  tricuspid  incompetence  is  present, 
when  there  will  be  the  ordinary  "  cardiac  "  oedema  into  the 
dependent  parts  of  the  body.  Occasionally,  however,  there 
is  a  very  noticeable  puffiness  in  the  lower  eyelids  on  rising 
in  the  morning,  which  passes  off  during  the  day,  leaving 
baggy,  wrinkled  pouches  below  the  eyes. 

It  is  in  red  granular  kidney  that  a  clear  understanding  of 


448  MEDICAL   DIAGNOSIS 

the  many  and  diverse  lesser  manifestations  of  uraemia  is 
essential  for  accurate  diagnosis,  since  all  the  symptoms 
which  are  not  referable  to  the  cardio-vascular  system  have 
almost  certainly  an  ursemic  origin. 

G.  The  Arterio -sclerotic  Kidney.  Any  cause  of  arterial 
degeneration  and  persistent  high  blood  pressure  will  sooner 
or  later  show  itself  by  a  fibrous  tissue  increase  in  the  renal 
interstitia,  and  the  arterio-sclerotic  kidney  is  the  result. 
Just  as  a  red  granular  kidney  causes  a  high  blood  pressure, 
so  does  a  high  blood  pressure  tend  to  cause  a  granular 
kidney,  and,  except  from  the  point  of  view  of  morbid 
anatomy,  the  lesions  are  identical.  Clinically  no  differences 
can  be  recognised  other  than  those  of  degree. 

H.  White  Granular  Kidney.  Very  diverse  opinions  have 
from  time  to  time  been  expressed  regarding  the  etiology 
of  this  disease.  Formerly  it  was  taught  that  the  large 
white  kidney  would,  if  the  patient  lived  long  enough, 
contract  into  the  white  granular  form  ;  others  deny  that 
this  ever  takes  place,  and  consider  that  the  white  granular 
kidney  is  always  a  distinct  entity  and  never  an  advanced 
stage  of  a  different  type  of  nephritis. 

Few  persons  of  wide  experience  in  morbid  anatomy  will 
deny  that  there  are  sometimes  found  at  post-mortem 
examinations  kidneys  which  present  an  intermediate  appear- 
ance between  the  large  and  small  white  kidneys  ;  but  such 
cases  are  rare,  and,  in  our  experience,  the  great  majority  of 
cases  of  white  granular  kidney  are  such  from  the  outset,, 
and  it  is  quite  exceptional  for  them  to  be  preceded  by  a 
chronic  tubal  nephritis. 

Histologically  there  is  extensive  change  in  both  the 
interstitial  and  parenchymatous  elements  of  these  kidneys. 

In  investigating  the  records  of  patients  dying  from  white 
granular  kidneys  the  following  features  are  noteworthy  : — 
(i.)  The  youthful  age  of  the  patient  (15  to  35  years),  the 

great  bulk  occurring  in  the  third  decade. 

(ii.)  The  absence  of  previous  scarlet  fever  in  any  greater 

frequency  than  in  healthy  people. 

(iii.)  The  absence  of  oedema  throughout  the  illness,  unless 

there  is  cardiac  failure  or  an  incidental  attack  of  acute 

nephritis  (both  of  which  are  likely  towards  the  end)» 


DISEASES   OF   THE   KIDNEY,   ETC.  449 

(iv.)  The  prevalence   of  albuminuric  retinitis,  which  is 

more  frequent  than  in  any  other  form  of  nephritis. 

(v.)  The  short  course  of  the  disease,  Avith  its  fatal  issue 

within  two  years  of  the  first  symptom. 

The  above  rather  suggests  that  these  cases  start  in  a  similar 
manner  to  the  red  granular  kidney,  but  that  for  some 
unexplained  reason  the  particular  toxins  involve  the 
parenchyma  (especially  the  glomerular  epithelium)  as  well 
as  the  interstitia,  with  the  result  that  the  renal  efficiency  is 
interfered  with  at  a  very  early  date  and  uraemia  is  ever  at 
hand. 

As  would  be  expected,  the  onset  is  insidious,  and  the  first 
thing  complained  of  is  often  headache,  general  debility, 
or  failing  vision.  Examination  shows  albuminuric  retinitis, 
cardiac  hypertrophy,  a  very  high  blood  pressure  (often  over 
200  mm.)  and  urine,  which  is  abundant,  of  rather  low  specific 
gravity  and  containing  a  fair  number  of  granular  and  fatty 
casts,  a  moderate  amount  of  albumin  (3  per  cent.),  and 
diminished  urea. 

The  progress  is  often  terribly  rapid,  death  occurring  in  the 
majority  of  cases  from  uraemia,  though  heart  failure  may 
sometimes  be  the  predominant  factor. 

Pericarditis  and  dry  pleurisy  are  common  at  the  end,  but 
serous  effusions  apart  from  heart  failure  are  not  frequently 
met  with. 

The  diagnosis  of  white  granular  kidney  presents  no 
difficulty  if  a  proper  examination  is  made,  but  many  of  the 
cases  are  treated  symptom atically  for  simple  headache,  and 
do  not  receive  adequate  investigation. 

In  conclusion  we  must  emphasise  the  fact  that  apparently 
obvious  cases  of  white  granular  kidney  may  be  found  to 
possess  some  other  variety  of  lesion  (sometimes  even  no 
very  obvious  lesion  at  all),  and  converselj'  cases  which 
clinically  suggest  the  presence  of  large  white  Iddneys  may, 
occasionally,  at  the  autopsy  prove  to  be  due  to  the  presence 
of  white  granular  kidneys. 

Morbid  Anatomy  and  Histology  of  Nephritis. 

In  view  of  the  fact  that  the  classification  of  nephritis 
a(loj)ted   in   the  preceding  pages  depends  on   the   morbid 
M.D.  29 


450  MEDICAL   DIAGNOSIS 

anatomy  of  the  kidneys  concerned,  a  short  description  of  the 
chief  naked-eye  and  microscopical  appearances  of  the 
varieties  of  diseased  kidney  is,  perhaps,  desirable. 

A.  Acute  Tubal  Nephritis,  (i.)  Naked  Eye.  The  kidney 
is  large,  rounded  and  congested  ;  the  capsule  strips  easily, 
exposing  dilated  venules  on  the  surface  of  the  organ.  On 
section  the  kidney  drips  blood  ;  the  pyramids  are  deep 
purplish-red  and  stand  out  distinctly  ;  the  cortex  is  ample 
in  width  and  striated  by  fine  red  lines.     The  pelvis  is  natural. 

(ii.)  Microscopically.  The  vessels  are  engorged  with 
blood.  The  tubal  epithelium  is  swollen  and  cloudy,  while 
in  places  it  can  be  seen  to  have  desquamated,  so  that  the 
tubules,  which  also  contain  blood,  appear  to  be  choked  up 
with  cells. 

B.  Acute  Glomerular  Nephritis,  (i.)  Naked  Eye.  But 
little  change  may  be  visible  ;  in  severe  cases  the  kidney  is 
large  and  engorged,  the  capsule  strips  readily  and  the 
glomeruli  can  be  seen  on  the  surface  of  the  organ  as  bright 
injected  dots.  On  section  the  cortex  is  abundant,  the 
pyramids  are  distinct,  and  the  whole  kidney  contains  an 
excess  of  blood. 

(ii.)  Microscopically.  The  most  striking  feature  is  the 
small  round-celled  infiltration  of  the  glomerular  tuft,  with 
dilatation  of  the  blood-vessels  and  the  presence  of  blood- 
cells  and  cellular  debris  within.  Bowman's  capsule.  The 
tubal  epithelium  may  be  secondarily  involved. 

C.  Acute  Pyelonephritis  (the  Surgical  Kidney),  (i.)  Naked 
Eye.  The  kidney  is  often  bulky  and  of  a  mottled  yellow 
colour,  and  abscesses  may  be  seen  through  the  capsule, 
which  usually  strips  fairly  easily.  On  section  the  pelvis  is 
acutely  inflamed  and  often  contains  pus,  whilst  its  size  is 
increased  from  atrophy  of  kidney  substance  if  back  pressure 
has  been  a  feature  of  the  case.  From  the  pelvis  yellowish 
lines  can  be  seen  running  up  amongst  the  pyramids ;  some- 
times the  abscesses  are  macroscopic,  but  frequently  the 
microscope  is  needed  for  their  detection.  In  early  cases 
the  inflammation  may  not  have  progressed  as  far  as  abscess 
formation.  Occasionally  the  kidney  is  converted  partially 
or  completely  into  a  bag  of  pus  (pyo -nephrosis). 

(ii.)  Microscopically.     The  feature  will  be  extensive  round- 


DISEASES   OF   THE   KIDNEY,   ETC.  451 

celled  infiltration,  peri -tubular  and  peri -vascular,  with  a 
varying  number  of  necrotic  areas  of  different  sizes.  The 
tubular  epithelium  is  disorganised  and  many  of  the  tubules 
are  disintegrated.  According  to  the  duration  of  the  disease 
so  will  there  be  more  or  less  interstitial  increase. 

D.  Large  White  Kidney,  (i.)  Naked  Eye.  The  kidney  is 
large,  pale  yellowish-white,  and  greasy-looking  ;  the  capsule 
strips  readily,  and  on  the  fatty  surface  stellate  veins  can  be 
observed.  On  section  the  cortex  is  increased  in  depth  and 
is  sharply  distinguished  from  the  pinkish  pyramids.  The 
pelvis  is  natural. 

(ii.)  Microscopically.  There  is  definite  and  diffuse  increase 
in  the  interstitial  tissue.  The  tubules  are  choked  with  the 
debris  of  fatty  and  granular  epithelium.  The  vessels  are 
moderately  hypertrophied  and  are  not  engorged  with  blood. 

E.  Chronic  Hsemorrhagic  Nephritis  (Large  Mottled  Kid- 
ney), (i.)  Naked  Eye.  The  kidney  is  large  and  mottled 
red  and  yellou  in  colour  ;  the  capsule  strips  readily,  al'nd  the 
kidney  can  be  seen  to  be  somewhat  engorged  with  blood. 
On  section  the  cortex  is  deep  and  the  pyramids  very  distinct 
and  of  a  much  darker  colour  than  in  the  large  white  kidney  ; 
there  is  often  a  certain  amount  of  cortical  striation  and  the 
whole  organ  contains  a  good  deal  of  blood. 

(ii.)  Microscopically.  The  appearances  are  those  of  the 
large  white  kidney,  except  that  the  vessels  are  engorged 
and  there  is  often  blood  in  the  tubules. 

F.  Red  Granular  Kidney,  (i.)  Naked  Eye.  The  kidney 
is  small,  red,  shrunken  and  tough  :  cortical  cysts  are  often 
visible  through  the  capsule  ;  the  capsule  may  be  adherent 
and  small  fragments  of  renal  cortex  may  be  left  sticking  to 
it  when  it  is  stripped  off,  but  in  manj^  cases  the  capsule 
strips  quite  easily  if  there  has  been  no  subacute  nephritis 
as  a  terminal  complication. 

The  surface  of  the  kidney  is  very  granular  and  often 
dotted  with  small  cysts  ;  the  granules  are  fine,  somewhat 
resembling  coarse  sand -paper.  On  section  the  cortex  is 
shrunken  till  the  pyramids  appear  almost  to  reach  the  surface, 
and  the  excess  of  fibrous  tissue  has  caused  a  loss  of  sharp 
differentiation  between  the  pyramids  and  the  rest  of  the 
organ.     The  pelvis  always  contains  an  excess  of  fat. 

29—2 


452  MEDICAL   DIAGNOSIS 

(ii.)  Microscopically.  The  arteries  are  greatly  thickened 
from  hypertrophy  of  the  media  ;  wedge-shaped  masses  of 
fibrous  tissue  can  be  seen  replacing  the  parenchyma  through- 
out the  organ,  but  between  the  fibrous  wedges  the  kidney 
substance  is  relatively  healthy.  In  the  diseased  areas 
the  tubular  epithelium  is  atrophied  and  lost,  the  tubules 
are  obliterated  or  distorted  into  small  cystic  spaces,  and 
the  glomeruli  are  converted  into  fibrous  masses  both  from 
pressure  from  without  and  also  from  becoming  filled  up 
by  fibrous  tissue  laid  down  round  the  vascular  tufts. 

G.  Arteriosclerotic  Kidney,  (i.)  Naked  Eye.  This  kidney 
is  not  necessarily  smaller  than  the  normal,  but  in  all  other 
respects  it  possesses  the  same  characteristics  as  the  red 
granular  kidney. 

(ii.)  Microscopically .  The  changes  are  those  of  the  red 
granular  kidney,  with  the  exception  that  they  are  not  so 
intense  in  degree  and  tend  to  be  more  diffuse  in  distribution. 

H.  White  Granular  Kidney,  (i.)  Naked  Eye.  This  kid- 
ney is  small,  pale  yellowish-white,  tough  and  shrunl?;en  ; 
cortical  cysts  are  often  present.  The  capsule  generally 
strips  cleanly,  but  may  be  adherent  in  places.  The  surface 
is  irregular,  but  the  "  granules  "  are  very  coarse  and  resemble 
rather  irregular,  lumpy  projections  than  the  coarse  sand- 
paper of  the  red  granular  kidney.  On  section  the  appear- 
ances are  identical  with  those  of  the  red  granular  kidney 
except  for  the  yellowish  colour,  which  probably  depends 
on  fatty  change  in  the  tubules. 

(ii.)  Microscopically .  The  arteries  are  much  thickened 
by  hypertrophy  of  the  media  ;  the  kidney  substance  is  the 
seat  of  diffuse  fibrous-tissue  replacement.  Such  tubules 
as  remain  show  epithelial  proliferation,  desquamation, 
and  fatty  change.  The  glomeruli  are  in  time  converted 
into  fibrous  masses,  but  this  is  accomplished  as  much  by 
proliferation  of  the  epithelium  lining  Bowman's  capsules 
as  by  the  methods  described  as  occurring  in  the  red  granular 
kidney.  This  proliferation  of  the  lining  epithelium  of  the 
Bowman's  capsules  and  subsequent  conversion  of  the 
cells  into  fibrous  tissue,  together  with  the  tubal  changes, 
constitute  the  characteristic  features  of  this  forin  of 
nephritis. 


DISEASES   OF   THE   KIDNEY,   ETC.  453 

II.  DEGENERATIONS  OF  THE  KIDNEY. 

(a)  Lardaceous  Disease.  It  is  rare  for  the  kidney  to  be 
the  only  organ  affected  ;  the  spleen  and  liver  are  nearly 
always  involved  as  well.  The  causes  are  prolonged  suppura- 
tion, especially  without  drainage,  tuberculosis  (especially  of 
bone),  and  syphilis. 

The  symptoms  are  those  of  the  primary  cause  plus  persis- 
tent albuminuria  ;  the  urine  is  at  first  plentiful,  but  in  the 
later  stages  it  is  diminished  ;  casts  (fatty  and  waxy)  are 
present,  but  only  in  small  numbers,  and  the  amount  of 
solids  is  diminished.  Albuminoid  casts — that  is  to  say, 
casts  giving  the  distinctive  staining  reactions  of  lardacein — 
have  often  been  described,  but,  in  our  experience,  they  do 
not  occur.  The  blood  pressure  is  low  and  the  cardio- 
vascular changes  of  true  nephritis  are  wanting.  It  has  been 
stated  that  persistent  albuminuria  with  a  low  blood  pressure 
is  diagnostic  of  lardaceous  kidneys,  and  certainly  it  is  very 
suggestive  ;  but  there  is  no  doubt  that  chronic  tubal 
nephritis  can  occur  in  the  subjects  of  wasting  diseases,  such 
as  tuberculosis,  cancer,  etc.,  without  the  ordinary  cardio- 
vascular sequela?  developing. 

A  lardaceous  kidney  is  large,  smooth,  tough,  rounded  and 
bulky  ;  the  capsule  strips  readily.  On  section  the  rounded 
edges  are  striking,  as  is  the  smeary,  par-boiled  appearance 
of  the  organ,  with  lack  of  clear  differentiation  between 
its  component  parts.  If  a  piece  of  lardaceous  kidney  be 
placed  for  a  few  minutes  in  a  solution  of  iodine  and  then 
washed  in  water  the  lardaceous  glomeruli  will  appear  as 
mahogany -brown  points. 

Microscopically  the  chief  feature  will  be  the  presence  of 
structureless  unstained  glomerular  patches,  unless  methyl 
violet  is  used  as  a  stain,  when  lardaceous  material  stains 
a  bright  magenta  colour. 

The  lardaceous  matter  itself  is  said  to  be  a  compound 
of  chondroitin-sulphuric  acid  with  an  albumin  ;  it  is  thought 
to  be  fanned  locally  and  is  deposited  as  white  crystalline 
j)lates  in  the  advent  it  ia  of  the  arterioles.  In  the  kidney 
the  arteries  to  the  glomeruli  are  the  first  to  be  affected. 

{b)  Fatty  Degeneration.    This  condition  is  not  likely  to  be 


454  MEDICAL   DIAGNOSIS 

recognised  clinically  ;  it  occurs  in  cases  of  prolonged  toxic 
or  septic  absorption,  after  the  ingestion  of  certain  proto- 
plasmic poisons,  such  as  phosphorus,  and  in  the  course  of 
the  graver  blood  diseases,  such  as  pernicious  anaemia  or  leu- 
kaemia. It  is  possible  that  the  large  white  kidney  is  really 
more  a  degeneration  (fatty)  than  an  inflammation. 

(c)  Granular  Degeneration  (cloudy  swelling).  This  condi- 
tion occurs  temporarilj^  whenever  there  is  high  fever ;  it  is 
therefore  a  common  manifestation  of  the  acute  specific 
infections.  A  slight  albuminuria  is  sometimes  found,  but 
casts  are  not  the  rule.  Complete  recovery  is  usual,  but  if 
the  primary  cause  is  unduly  prolonged  fatty  degeneration 
may  ensue. 

III.    VASCULAR    DISTURBANCES    OF    THE 
KIDNEYS. 

(a)  Active  Congestion.  This  must  occur  as  the  result  of 
irritation,  whether  dhect  or  reflex,  and  is  best  seen  in  the 
early  stages  of  acute  nephritis,  to  which  condition  the 
symptoms,  if  any,  will  point. 

(b)  Passive  Congestion.  This  is  produced  in  its  most 
typical  form  by  heart  failure  in  mitral  disease.  Mechanical 
obstruction  of  the  renal  veins  by  tumour,  ascites,  or  ovarian 
cysts  are  less  frequent  causes.  The  urme  in  svich  cases  is 
apt  to  be  scanty,  high-coloured  and  albuminous,  but  the 
urea  is  not  notably  diminished. 

(c)  Infarction.  A  renal  infarct  may  be  accompanied  by 
pain  in  one  or  other  loin,  but  quite  often  hsematuria  is  the 
only  symptom.  A  few  blood  casts  can  usually  be  found. 
The  diagnosis  is  suggested  by  the  discovery  of  endocarditis 
of  the  left  heart. 

IV.   PYELITIS. 

Consecutive  Pyelitis  due  to  an  ascending  infarction  from 
the  bladder  is  but  a  stage  in  the  course  of  pyelo-nephritis 
which  has  already  been  considered. 

In  Calculus  Pyelitis  the  symptoms  of  calculus  may  over- 
shadow those  of  pyelitis,  but  not  infrequently  it  is  the  pyelitis 
which  claims  attention,  the  calculus  being  found  subse- 
quently by  the  X-rays. 


DISEASES   OF   THE  KIDNEY,   ETC. 


455 


Tuberculous  Pyelitis  has  been  considered  in  the  section 
on  "  Tuberculosis." 

Primary  Pyelitis  is  generally  the  result  of  an  infection 
with  Bacillus  coli.  In  the  majority  of  cases  the  infection 
is  probably  hsematogenous ;  a  lymphatic  route  is  a  possibility, 
as  also  is  an  ascending  infection  from  the  bladder,  but  this 
last  is  improbable  so  long  as  the  mechanism  of  micturition 
is  in  no  way  impaired — that  is  to  say,  so  long  as  there  is  no 
obstruction,  either  mechanical  or  paralytic,  to  the  free  void- 
ing of  the  urine. 

Acute  Pyelitis  is  seen  principally  in  two  great  classes,  first, 


106' 
105' 

/03° 

loir 

101' 
100' 
99' 
98' 

ar 

96' 

M    E 

M    E 

M   E 

M   C 

ME 

M  E 

M  E 

ME 

M   E 

M   E 

M  £ 

M  E 

A 

: 

(■ 

\A 

/ 

■  \ 

•A 

k 

■   / 

'^ 

J 

\ 

7 

f\ 

V 

/ 

■\ 

/ 

/\ 

*^- 

... 

«■ 

.. 

... 

*  ^* 

•?■ 

... 

V'* 

*-- 

t^^ 

n"^ 

rr" 

_ 

Fig.  CA. — Chart  from  a  case  of  Acute  Pyelitis 
(Juo  to  infection  with  Bacillus  coli. 

women  after  childbirth,  and  secondly,  infants  and  young 
children. 

The  symptoms  are  those  of  any  acute  infection — shivering, 
malaise,  headache,  and  fever.  At  the  same  time  there  will 
usually  be  severe  pain  in  the  loins  (one  or  both)  and  definite 
tenderness  in  the  angle  between  the  spine  and  the  twelfth 
rib.  The  urine  contains  many  pus  cells  and  bacilli ;  albumin 
and  sometimes  blood  are  present,  as  well  as  epithelial  cells 
from  the  pelvis  of  the  kidney.  The  amount  of  urine  is 
diminished  in  severe  cases,  but  there  are  no  casts.  In  the 
majority  of  cases  one  kidney  only  is  affected.  The  infection 
may  be  so  severe  as  to  necessitate  nephrectomy,  but  in 
the  generality  of  cases  the  symptoms  subside  under  appro- 
priate treatment  in  the  course  of  a  week  or  two. 

In  children  cure  is  usually  complete,  but  in  adults  recovery 
is  often  imperfect,  and  a  chronic  pyelitis  or  chronic  bacilluria 
is  left  behind  to  prove  a  source  of  worry  for  many  years. 


456  MEDICAL  DIAGNOSIS 

Chronic  Pyelitis,  as  stated  above,  may  follow  the  acute 
variety  ;  it  may  also  develop  insidiously.  There  may  be  a 
dull  aching  pain  in  the  back,  but  not  infrequently  the  most 
prominent  symptoms  are  those  of  neurasthenia.  A  movable 
kidney  is  found  in  some  cases  ;  in  others  it  is  enlarged  and 
tender.  The  urine  is  acid  and  contains  pus  cells  and  bacilli, 
but  not,  as  a  rule,  more  albumin  than  can  be  explained  by  the 
amount  of  pus  present. 

In  the  mildest  type  of  all  no  pus  cells  are  present  in  the 
urine — indeed,  nothing  abnormal  can  be  found  except 
numbers  of  bacilli. 

The  diagnosis  of  pyelitis  rests  on  the  urinary  examination, 
reinforced,  if  necessary,  by  cystoscopy  to  examine  the 
effluent  from  each  ureter,  the  ureteric  orifices,  and  the  condi- 
tion of  the  mucous  membrane  of  the  bladder. 

Calculus  must  be  excluded  by  X-ray  examination. 

Acute  nephritis  can  be  excluded  by  the  excess  of  pus  cells 
and  the  presence  of  bacilli. 

V.  URINARY  CALCULUS. 

A  stone  may  lie  imbedded  m  the  kidney  or  renal  pelvis 
for  years  without  giving  rise  to  symptoms.  The  usual 
symptoms  of  renal  calculus  are  :  pain  and  hsematuria, 
though,  as  stated  above,  the  symptoms  of  acute  pyelitis 
may  be  the  first  clue  to  the  diagnosis  of  stone.  The  pam  is 
referred  to  the  loin  of  the  affected  side,  but  also  radiates 
to  the  groin,  testicle,  and  inner  side  of  the  thigh  on  the 
same  side. 

If  the  calculus  is  in  the  ureter,  renal  colic  is  a  likely  event. 

The  pain  of  renal  colic  is  probably  as  severe  as  any  known 
form  of  pain  ;  it  has  the  same  distribution  as  the  pain  of 
renal  calculus  described  above,  but  occurs  in  paroxysms  of 
the  utmost  violence  and  is  associated  with  vomiting,  sweating, 
collapse,  retraction  of  the  testicle,  and,  nearly  always, 
hsematuria  in  acid  urine.  If  the  calculus  becomes  impacted 
at  the  opening  of  the  ureter  into  the  bladder  no  urine  will 
be  secreted  by  the  affected  kidney,  and  if  the  other  kidney 
is  diseased  reflex  suppression  of  urine  may  occur  on  that  side 
also.     The  result  is  complete  anuria. 


DISEASES   OF   THE   KIDNEY,    ETC.  457 

Renal  Colic  clue  to  stone  must  be  distinguished  from  the 
following  : — 

(i.)  Acute  Pyelitis,  in  which  the  pain  may  be  so  severe 
as  to  sunulate  renal  colic. 

(ii.)  DietVs  Crises,  which  are,  in  effect,  attacks  of  renal 
colic  associated  mth  a  movable  kidney  and  periodic 
kinking  of  the  ureter ;  the  palpable  kidney  and  the  absence 
of  hsematuria  may  suggest  the  diagnosis. 

(iii.)  Intestinal  Colic,  in  which  the  pain  has  a  quite 
different  distribution  and  is  usually  accompanied  by 
flatulent  distension  of  the  bowel. 

(iv.)  Biliary  Colic,  in  which  the  pain  is  referred  princi- 
pally to  the  right  hypochondrium  and  through  the  right 
chest  to  the  right  shoulder,  and  in  which  the  history 
wiU  generally  point  to  the  liver  or  bile  apparatus  as  a 
probable  focus. 

In  cases  of  doubt  an  adequate  X-ray  examinatioi)  will 
generally  enable  Renal  Calculus  to  be  excluded. 

Stone  in  the  Bladder  is  usually  accompanied  by  alkaline 
urine,  and  there  are  frequency  of  micturition,  strangury, 
hsematuria  and  pyuria,  while  the  pain  from  irritation  of 
the  trigone  is  referred  to  the  end  of  the  penis  as  well  as  to 
the  perinaeum  and  neck  of  the  bladder. 

VI.  ANURIA. 

Urine  may  fail  to  be  secreted  in  the  followmg  circum- 
stances : — 

(i.)  Acute  Nephritis.  Here  the  suppression  is  rarely 
complete  for  more  than  thirty-six  hours. 

(ii.)  Ureteric  Obstruction,  either  by  calculus  or  by  mas.ses 
of  pus  and  epithelial  debris.  The  obstruction  may  be 
bilateral,  but  anuria  may  follow  unilateral  obstruction 
if  the  other  kidney  is  diseased. 

(iii.)  Acute  Pyelitis. 

(iv.)  Massive  Necrosis  of  the  Renal  Cortex.  This  condition 
has  been  recorded  about  a  dozen  times.  It  occurs  in  associa- 
tion with  parturition,  or  sometimes  with  eclampsia,  or  it 
may  be  associated  with  no  apparent  cause.  In  some  cases 
there  has  been  thrombosis  of  the  ovarian  and  renal  vessels 


458  MEDICAL  DIAGNOSIS 

but  more  often  an  ob liter ative  lesion  has  been  found  in 
the  smaller  renal  arteries. 

Where  anuria  persists  the  symptoms  are  relatively  slight ; 
the  most  prominent  are  vomiting,  dyspnoea  and  towards  the 
end  slight  twitchmg.  The  mental  faculties  are  unimpaired, 
but  death  occurs  quite  suddenly  from  the  seventh  to  the 
twelfth  day  of  suppression.  A  striking  feature  of  these  cases 
of  anuria  is  the  absence  of  ordinary  urgemic  phenomena. 

VII.    URAEMIA. 

By  uraemia  is  meant  the  symptomatic  expression  of 
serious  renal  insufficiency.  A  variety  of  explanations  have 
been  advanced  from  time  to  time  to  account  for  these 
symptoms,  but  so  far  nothing  altogether  satisfactory  has 
been  evolved.  The  physical  explanations  of  Rees  and 
Ascoli  respectively  that  uraemia  depends  upon  oedema  of 
the  nervous  system  and  meningeal  inflammation  are  not 
supported  by  pathological  findings.  Of  chemical  theories 
the  following  may  be  mentioned  : — 

(i.)  Retention  of  Normal  Products  of  Metabolism.  Reten- 
tion of  urine  does  not  cause  uraemia,  and  although  urine  is 
toxic  if  injected  into  animals  the  symptoms  are  not  those 
of  uraemia  ;  again,  the  urine  in  uraemia  is  not  less  toxic  than 
in  health. 

(ii.)  Retention  of  the  Products  of  Ab^iormal  Metabolism  or 
their  interaction  to  form  some  definitely  toxic  body.     On 
this  hypothesis  the  following  bodies  have  been  suggested  : — ■ 
{a)  Urea.     This,  however,  is  only  toxic  in  very  large 

amounts. 

(6)  Ammonium    Carbonate.     This    does    not    produce 

uraemia  when  injected. 

(c)  Potassium  Salts.  These  do  not  produce  uraemia 
when  injected. 

(d)  Creatinin  ;  Pigments  ;  Chlorides  ;  Uric  Acid.  All 
these  are  present  in  certain  diseases  (without  producing 
the  symptoms  of  uraemia)  in  greater  amounts  than  are 
found  in  uraemia. 

(iii.)  Acidosis.  The  occurrence  of  coma  in  both  uraemia 
and  diabetes,  coupled  with  the  proved   hypo-alkalinity  of 


DISEASES   OF   THE   KIDNEY,   ETC.  459 

the  blood  in  the  latter,  has  suggested  the  possibility  of  some 
analogous  '"'  acidosis  "  occurrmg  in  uraemia.  The  remaining 
sj'mptoms  of  uraemia  are,  however,  widely  different  from 
those  of  the  acid  intoxications,  and,  further,  the  treatment 
which  is  successful  in  the  latter  is  without  avail  in  uraemia. 

(iv.)  Trimethylamine.  This  body  is,  chemically,  closely 
related  to  neurine,  and  the  symptoms  which  follow  the 
painting  of  the  cerebral  cortex  with  neurine  somewhat 
resemble  the  sj-mptoms  found  in  certain  cases  of  severe 
uraemia.  Further,  the  characteristic  odour  of  uraemic 
patients  is  not  unlilve  that  of  trimethylamine,  and  it  has  been 
shown  by  Golla  that  the  blood  of  uraemic  patients  contains 
as  much  as  ten  times  the  normal  content  of  trimethyla- 
mine. 

(v.)  The  internal  secretion  of  the  kidney  has  been  shown 
by  Bradford  to  exercise  an  inhibitory  action  on  proteid  meta- 
bolism. If,  therefore,  the  renal  disease  causes  a  diminution 
of  internal  secretion,  there  will  be  a  corresponding  increase 
in  the  blood  and  tissues  of  the  bye-products  of  proteid 
metabolism.  This  may  help  to  explain  how  the  specific 
uraemic  toxin  is  formed,  but  it  does  not  tell  us  what  it  is. 

Clinically  uraemia  may  be  divided  into  acute,  chronic, 
and  latent  forms. 

(a)  Acute  Uraemia.  Here  the  symptoms  are  mainly  of 
nervous  origin  and  may  show  themselves  with  the  suddenness 
of  an  apoplexy.  Convulsions,  coma,  mania,  and  delusional 
insanity  are  all  common  ;  the  convulsions  may  be  followed 
by  amaurosis. 

Paralysis  either  of  isolated  muscle  groups  or  even  hemi- 
plegia may  occur,  while  headache  and  giddiness  are  the  rule. 
Gastro-intcstinal  symptoms,  such  as  obstinate  vomitmg 
and  diarrhoea  or  severe  abdominal  pain,  may  be  present, 
and  respiratory  symptoms,  such  as  dyspnoea  (either  con- 
tinuous or  paroxysmal)  and  Cheyne-Stokes  breathing,  are  of 
frequent  occurrence. 

Other  manifestations  are  formication,  erythematous 
eruptions,  and  intense  itching  of  the  skin.  The  temperature 
is  not  characteristic,  but  is  more  likely  to  be  low  than  high 
except  anIu'II  flic  convulsions  have  been  of  extreme  severity. 

{b)  Chronic  Uraemia.     The  symptoms  are  the  same  as  in 


460  MEDICAL  DIAGNOSIS 

the  acute  form  but  they  are  less  severe  and  come  on  more 
gradually.  Often  one  symptom  or  group  of  symptoms  may 
be  the  only  evidence  of  uraemia  for  many  weeks. 

(c)  Latent  Urcemia.  This  has  been  considered  under 
the  heading  "  Anuria."  Beyond  slight  twitching  and  a 
tendency  to  vomiting  and  dyspnoea  no  symptoms  are  to 
be  observed. 

The  diagnosis  of  uraemia  may  be  a  matter  of  extreme 
difficulty.  In  chronic  cases  the  examination  of  the  urine 
combined  with  a  consideration  of  the  cardio-vascular 
system  should  at  least  prove  the  existence  of  nephritis  and 
hence  suggest  a  cause  for  any  seemingly  obscure  symptom  ; 
but  it  must  be  confessed  that,  at  present,  we  cannot  deter- 
mine from  an  analysis  of  the  urine  whether  uraemia  is 
present  or  even  imminent. 

The  principal  difficulty,  however,  arises  in  the  case  of 
patients  who  are  first  seen  when  in  an  unconscious  condition, 
and  it  is  especially  important  to  attempt  to  differentiate 
uraemia  from  the  following  : — 

(i.)  Acute  AlcoJiolisrn.  Here  the  odour  of  the  breath  may 
be  suggestive,  but  it  must  be  remembered  that  brandy  is 
usually  administered  "  on  sight  ""  to  any  unconscious  person. 
An  urcemic  odour  is  important.  The  pupils  in  alcoholic 
coma  are  usually  dilated  ;  in  uraemia  they  are  variable,  but 
generally  are  either  medium  or  dilated.  The  alcoholic  can 
usually  be  roused  temporarily.  If  there  is  any  doubt  a 
catheter  specimen  of  urine  should  be  drawn  off  and  examined 
for  alb u mm  and  casts. 

(ii.)  Opium  Poisonmg.  Here  the  pupils  are  pin-point 
and  there  is  no  albuminuria,  while  the  characteristic  odour 
of  opium  may  be  perceived  in  the  breath. 

(iii. )  ' '  Apoplexy.' '  The  face  is  blue  and  swollen  ;  the  stertor 
is  profound ;  the  pupUs  are  variable,  they  may  be  unequal 
and  fixed  ;  there  may  be  conjugate  deviation  of  the  head 
and  eyes  and  definite  paralysis  on  one  side  of  the  body. 

(iv.)  Diabetic  Coma.  The  smell  of  apples  may  be  noticed 
in  the  patient's  breath  and  sugar  is  present  in  the  urine. 

(v.)  Epilepsy.  The  fits  are  brief  and  usually  followed  by 
sleep  ;  there  is  usually  no  albuminuria. 


DISEASES   OF  THE   KIDXEY,   ETC.  461 

VIII.  MOVABLE  KIDNEY. 

This  affection  is  much  more  common  in  women  than 
men  and  in  the  spare  than  in  the  stout.  The  right  kidney 
is  practically  always  the  first  to  be  affected,  though  the  left 
may  follow  suit.  When  both  are  affected  there  is  usually 
a  condition  of  general  visceroptosis.  The  symptoms  of 
movable  kidney  may  be  general  or  local. 

The  general  symptoms  are  those  of  neurasthenia  which 
may  develop  into  melancholia  or  delusional  insanity.  The 
local  symptoms  are  a  dragging  pain  in  the  back  or  loin  and 
sometimes  the  periodical  occurrence  of  Dietl's  crises,  which 
are  identical  with  attacks  of  renal  colic.  Dyspepsia  is  very 
commonly  present  and  menorrhagia  is  far  from  rare. 

The  diagnosis  of  movable  kidney  can  be  made  by  physical 
examination,  preferably  with  the  patient  half  sitting  up. 
One  hand  should  be  placed  at  the  back  and  the  other  below 
the  costal  margin.  If  the  hands  are  now  approxunated  the 
kidney  can  be  grasped  between  them  and  will  be  found  to 
move  up  and  down  with  respiration  and  also  by  the  action 
of  gravity.  The  contour  of  the  organ  can  usually  be  well 
appreciated,  and  thus  it  can  be  distinguished  from  a  renal 
tumour  in  the  majority  of  instances. 

IX.  RENAL  TUMOURS 

(Including  enlargements  not  due  to  new  growth). 

The  general  characteristics  by  which  an  abdominal  tumour 
may  be  suspected  to  be  of  renal  origin  are  as  follows  : — 

(i.)  The  mass  seems  to  be  growing  from  the  deep  tissues 
of  the  loin  forwards  into  the  abdominal  cavity. 

(ii.)  It  can  be  grasped  between  the  palms  of  the  hands,  if 
one  be  placed  behind  over  the  twelfth  rib  and  the  other  in 
front  below  the  costal  margin. 

(iii.)  It  moves  definite!}^  on  respiration. 

(iv.)  Unless  of  very  large  size,  a  band  of  resonance  may 
be  detected  superficial  to  the  mass  so  long  as  there  is  gas 
in  the  colon. 

(\ .)  Variations  in  size  coincident  with  the  passage  of 
largo  amounts  of  {a)  urine,  point  to  hydronephrosis,  or  {b) 
pus,  to  pyonephrosis. 


462  MEDICAL   DIAGNOSIS 

On  the  left  side  a  renal  tumour  must  be  distinguished  from 
spleen,  fundus  of  stomach,  splenic  flexure  of  descending 
colon,  retro -peritoneal  sarcoma,  and  perinephric  abscess  : 
on  the  right  side  from  liver,  gall-bladder,  pylorus,  hepatic 
flexure  of  colon,  retro -peritoneal  sarcoma,  and  perinephric 
abscess. 

In  all  cases  examination  of  the  urine  may  be  of  the  greatest 
assistance,  but  the  following  points  should  be  remembered  : — - 
(a)  A  Perinephric  Abscess  should  be  suspected  if  there 
is  marked  dulness  in  the  loin,  oedema,  and  the  constitu- 
tional disturbance  of  sepsis. 

(6)  A  Retro -peritoneal  Sarcoma  is  often  indistinguishable 
from  a  renal  tumour,  but  rapid  growth  in  all  directions  or 
the  occurrence  of  such  a  mass  in  childhood  and  without 
hsematuria  is  suggestive. 

(c)  Spleen.  An  enlarged  spleen  appears  to  be  much 
more  superficial  than  a  renal  tumour  ;  it  seems  to  be 
growing  from  beneath  the  costal  margin,  it  is  dull  to  per- 
cussion, and  the  dulness  merges  into  the  ordinary  splenic 
dulness.     A  blood  examination  should  be  made. 

(d)  Colon.  Such  masses  are  either  very  freely  movable 
or  else  definitely  fixed  owing  to  the  infiltration  of  sur- 
rounding structures.  Their  shape  is  most  irregular  ; 
there  are  usually  symptoms  of  chronic  intestinal  obstruc- 
tion, and  they  are  noticeably  more  superficial  than  a 
renal  tumour. 

(e)  Liver  and  Gall  Bladder.  These  again  are  more 
superficial  than  renal  tumours,  while  a  gall-bladder  may 
present  a  characteristic  oval  shape.  They  are  dull  to 
percussion  and  the  dulness  merges  into  the  normal  liver 
dulness,  but  the  edge  of  the  liver  can  usually  be  felt  above 
the  neck  of  the  gall  bladder.  Symptoms  referable  to  the 
liver  or  bile  apparatus  may  be  present. 

(/)  None  of  these  tumours,  except  possibly  an  enlarged 
spleen,  can  be  so  definitely  grasped  between  the  hands  as 
can  a  renal  tumour. 

Renal  Tumours  not  due  to  New  Growth: — 
(i.)  Hydronephrosis.     This  condition  is  produced  by  any 
intermittent    obstruction    to  the   outflow    of    urine    from 
the  ureter.     A  ureteric  calculus  is  a  common  cause.     The 


DISEASES   OF  THE   KIDNEY,   ETC.  463 

physical  signs  are  the  presence  of  a  renal  tumour,  which 
often  preserves  closely  the  outline  of  a  normal  kidney 
and  which  varies  in  size  from  day  to  day,  diminution  occurring 
simultaneously  with  the  voiding  of  large  quantities  of  pale 
urine. 

The  general  health  may  be  quite  good,  but  a  history  of 
renal  or  ureteric  calculus  is  not  improbable.  In  a  few  cases 
the  hydronephrotic  sac  may  be  so  large  as  to  simulate 
free  fluid  in  the  peritoneum  or  an  ovarian  cyst. 

(ii.)  Pyonephrosis.  This  condition  is  precisely  analogous 
to  hydronephrosis  except  for  the  contents  of  the  sacculated 
kidney,  which  are  purulent.  Therefore  the  physical  signs 
will  be  the  same  except  for  pyuria,  but  the  symptoms 
will  be  those  of  septic  absorption. 

(iii.)  Congenital  Cystic  Disease.  This  is  a  bilateral  affec- 
tion in  which  the  kidneys  are  converted  into  cystic  masses 
which  grow  bigger  with  advancing  years.  They  are  dis- 
covered accidentally  and  perhaps  not  till  the  foul-th  or 
fifth  decades  of  life.  Patients  suffering  from  them  usually 
perish  of  uraemia  before  the  age  of  fifty.  The  urine  generally 
approximates  in  type  to  that  of  a  red  granular  kidney. 
Hsematuria  is  not  infrequent. 

The  diagnosis  of  congenital  cystic  kidney  should  prove 
a  contra-indication  to  any  surgical  operation  if  this  can 
possibly  be  avoided,  for  uraemia  is  only  too  likely  to  follow 
the  operation. 

Renal  New  Growths.  These  may  be  innocent  or  malignant, 
and  the  latter  may  be  primary  or  secondary. 

A.  Innocent  Tumours,  (i.)  Hypernephroma.  These 
tumours  are  said  to  arise  in  misplaced  fragments  of  adrenal 
tissue  ;  they  are  potentially  malignant,  but  often  remain 
"  innocent  "  throughout  their  course.  The  presence  of  a 
renal  tumour  may  first  suggest  the  diagnosis  unless  tlie 
growth  has  encroached  on  the  pelvis  of  the  kidney,  in  which 
case  ha'maturia  may  be  the  first  sign.  Cystoscopy  will 
show  tliat  the  blood  is  coming  from  one  kidney  only,  and  if 
blood  diseases,  tuberculosis,  and  calculus  are  excluded 
the  only  diagnosis  left  is  new  growth  or  renal  epistaxis. 
This  question  and  the  nature  of  the  tumour  can  only  be 
settled  by  exploratory  operation. 


464  MEDICAL   DIAGNOSIS 

(ii.)  Adenomata  call  for  no  special  description  ;  they  rarely 
reach  sufficient  size  to  give  rise  to  symptoms. 

B.  Malignant  Tumours.  These  may  be  carcinoma  or 
sarcoma.     The  latter  are  not  uncommon  in  small  children. 

The  remarks  made  on  hypernephroma  apply  with  equal 
force  to  malignant  renal  tumours,  but  removal  by  operation 
is  necessarily  not  so  hopeful  in  the  latter  case. 

In  cases  in  which  the  growth  is  secondary  no  operation 
should  be  attempted. 

Ha^maturia  is  an  early  sign  in  more  than  50  per  cent,  of  all 
malignant  renal  tumours. 


X.  THE  ESTIMATION  OF  THE  RENAL  FUNCTION. 

Various  methods  have  been  devised  with  a  view  to 
estimating  the  functional  activity  of  the  kidneys,  but  it 
must  be  admitted  that  from  a  purely  medical  aspect  the 
results  are  of  little  value,  either  from  a  diagnostic  or  prog- 
nostic point  of  view,  in  cases  of  nephritis. 

From  a  surgical  point  of  view,  however,  some  of  these 
tests  are  of  great  importance  since,  if  it  is  proposed  to  remove 
one  kidney,  it  is  desirable  to  know  that  the  remaining 
kidney  is  lilvely  to  prove  equal  to  the  increased  demands 
that  will  be  made  upon  it. 

It  is  not  too  much  to  say  that  a  nephrectomy  should 
never  be  performed  without  a  preliminary  cystoscopy  and 
approximate  estimation  of  the  renal  function. 
The  following  investigations  should  be  made  : — 

(a)  Cryoscopic  determinations  of  the  blood  and  of  the 
urine,  obtained  by  catheterisation  of  the  ureters.. 

The  freezing  pomt  of  a  fluid  is  lowered  to  an  extent  pro- 
portional with  the  number  of  molecules  of  solid  sub- 
stances which  are  dissolved  in  it.  By  this  means  it  can 
be  shown  whether  the  blood  contains  an  excess  of  solids, 
and  if  this  is  so  it  is  suggestive  of  a  total  renal 
insufficiency.  The  freezing  points  of  the  separated  urines 
will  show  which  kidney  is  principally  at  fault. 

It  must  be  remembered  that  the  technique  is  extremely 
difficult  and  altogether  beyond  the  scope  of  the  prac- 


DISEASES   OF   THE   KIDNEY,    ETC.  465 

titioner,  but  if  properly  carried  out  it  affords  some  indica- 
tion of  the  osmotic  efficiency  of  the  kidneys. 

(6)  Injection  of  Phloridzin.  This  experiment  depends 
on  the  fact  that  after  the  subcutaneous  injection  of 
phloridzin  a  healthy  kidney  will  excrete  an  amount  of 
sugar  proportional  to  the  amount  of  phloridzin  injected, 
and  that  the  sugar  will  appear  in  the  urine  within  a 
certain  time  of  injection  and  will  cease  a  certain  time 
later. 

Accordingly  cystoscopy  is  performed,  and  catheters 
left  in  the  ureters  (practically  it  is  sufficient  to  catheterise 
one  ureter  and  collect  the  urine  from  the  other  kidney 
via  the  bladder),  and  at  the  sam.e  time  005  gm.  of  phlorid- 
zin is  injected  beneath  the  skin. 

The  effluent  from  each  kidney  is  received  into  sterile 
bottles,  which  are  changed  every  thirty  minutes  for 
three  hours.  A  healthy  kidney  shows  sugar  in  its  urine 
after  half  an  hour,  and  secretes  from  "5  to  2' 5  gilis.  of 
sugar  during  the  next  two  hours,  after  which  no  more 
sugar  is  found. 

Should  the  urine  contain  less  than  "5  gm.  a  serious 
renal  inadequacy  may  be  presumed.  This  may  be  con- 
firmed by  urea  estimation. 

(c)  The  Diastase  Reaction,  vide  p.  404, 

(d)  Simple  Cystoscopy  may  show  that  there  is  no  kidney 
on  one  side  or  that  (in  cases  of  tuberculosis)  both  kidneys 
are  affected  and  that  an  operation  should  be  avoided. 
{Vide  also  article  on  "  Tuberculosis,"  p.  102.) 

XI.    INFLAMMATION    OF    THE    BLADDER 
(CYSTITIS). 

A  bacterial  invasion  of  the  bladder  is  the  immediate  cause 
of  cystitis,  but  there  may  be,  and  often  is,  bacilluria  without 
cystitis.  Additional  factors  which  encourage  any  bacteria 
that  may  be  present  to  .set  up  active  inflammation  are  cither 
traumatic — for  example,  the  presence  of  a  calculus  or  the 
ova  of  bilharzia  ;  the  faulty  use  of  a  catheter  ;  the  presence 
of  a  new  growth  ;  or  anything  which  allows  the  urine  to 
stagnate,   such    as    retention   from   stricture    or    enlarged 

M.D.  30 


466  MEDICAL  DIAGNOSIS 

prostate,  in  cases  of  paraplegia,  or  when  there  is  a  vesical 
saccule.  Some  cases  appear  to  be  spontaneous  and  follow 
a  chill  or  exposure. 

Cystitis  is  usually  divided  into  acute  and  chronic  forms, 
but  all  grades  of  inflammation  may  be  met  with  from  catarrh 
to  gangrene. 

Acute  Cystitis  is  characterised  by  severe  pain  in  the 
hypogastrium,  frequency  of  micturition,  strangury  and  the 
passage  of  blood,  pus  and  epithelium.  The  urine  is  usually 
acid.  The  pam  is  often  referred  to  the  perinaeum,  and  in 
men  to  the  glans  penis. 

Chronic  Cystitis.  This  may  follow  an  acute  attack  or 
develop  insidiously. 

The  symptoms  are  the  same  as  those  of  acute  cystitis,  but 
usually  much  less  severe  ;  indeed,  in  mild  cases  there  may 
be  none  at  all.  The  urine  contains  pus,  ropy  mucous  and 
epithelium,  and  is  alkaline  unless  the  organism  is  the  tubercle 
bacillus,  a  member  of  the  Bacillus  coli  group,  or  sometimes 
the  gonococcus. 

When  cystitis  has  existed  for  a  long  time  the  bladder  walls 
become  thickened  and  contracted  and  are  often  encrusted 
with  phosphates. 

Diagnosis  of  Cystitis.  The  presence  of  pus  in  the  urine 
means  inflammation  of  the  kidney  or  bladder,  if  urethral 
or  prostatic  affections  can  be  excluded. 

If  there  is  no  more  albumin  present  than  would  be 
explained  by  the  pus,  and  if  the  urea  output  is  normal,  the 
probability  is  that  the  kidney  is  sound  (unless  possibly  there 
is  pyelitis  :  vide  p.  454).  Pain  in  the  hypogastrium,  perinseum 
and  penis  strongly  suggests  inflammation  of  the  bladder,  as 
does  the  presence  of  much  mucus  in  the  urine. 

In  cases  which  do  not  clear  up  quickly  and  for  which  no 
obvious  cause  can  be  found  it  is  advisable  to  examine  the 
bladder  with  a  cystoscope,  as  by  this  means  the  condition 
of  the  mucous  membrane  can  be  determined,  as  well  as  the 
presence  of  calculi,  sacculations,  and  new  growths.  Further, 
the  condition  of  the  kidneys  can  be  estimated  by  looking 
at  the  ureteric  orifices  and  by  observing  the  jets  of  urine 
from  each. 

Tuberculosis    can    be    excluded    by    cystoscopy  or    by 


DISEASES   OF   THE  KIDNEY,   ETC.  467 

repeatedly  examining  the  urine  for  tubercle  bacilli,  or  by 
injecting  some  of  the  urinary  sediment  into  a  guinea-pig. 

Vesical  calculus  can  be  detected  by  the  passage  of  a  sound, 
by  X-rays  or,  in  children,  by  bimanual  examination  of  the 
abdomen  with  one  finger  in  the  rectum. 


30—2 


PART  Y 

DISEASES   OF  THE   NERVOUS   SYSTEM. 

CHAPTER  I 

ANATOMICAL  AND  PHYSIOLOGICAL 
CONSIDERATIONS. 

I.  The    Tracts    in    the    Central    Nervous    System.     The 

physiological  function  of  the  nervous  system  is  to  receive 
impulses  or  stimuli  (conscious  or  unconscious)  from  the 
various  organs  and  from  the  periphery  generally,  to  convey 
these  afferent  stimuli  to  appropriate  cell  centres  in  the  brain 
or  cord,  and  to  respond  to  them  by  such  efferent  impulses  as 
may  be  required. 

Just  as  the  afferent  impulses  may  be  conscious  or  uncon- 
scious, so  may  the  efferent  ;  indeed,  practically  the  whole 
of  the  processes  necessary  for  adequate  metabolism  and 
ordinary  existence  are  carried  out  unconsciously.  The 
processes  that  take  place  between  the  reception  of  an  afferent 
impulse  and  the  resulting  performance  of  a  voluntary  action 
are,  perhaps,  the  simplest  form  of  thought. 

In  order  to  make  a  correct  diagnosis  in  many  cases  of 
disease  of  the  nervous  system  it  is  first  essential  to  locate 
the  position  of  the  lesion  or  lesions  as  accurately  as  possible. 
This  can  only  be  accomplished  by  a  satisfactory  understand- 
ing of  the  anatomy  of  the  nervous  sj^stem  both  central  and 
peripheral. 

The  Central  Nervous  System  consists  of  the  Brain  and 
Spinal  Cord.  The  brain  is  the  site  of  the  most  highly 
specialised  groups  of  cells  and  is  the  seat  of  consciousness. 
The  spinal  cord  is  a  mass  of  conducting  fibres  between  the 
brain  and  the  periphery,  but  contains,  in  addition,  certain 
cell  stations  between  individual  conducting  fibres  and  also 
the  cell  nuclei  for  all  the  motor  portions  of  the  spinal  nerves. 


Fia.  Go, — Diagram  to  show  the  arrangeraint 
of  the  motor  and  sensory  fibres  in  the 
Internal  Capsule. 

CN  =  Candate  Nucleus. 
LN  =  Lcnticuhir  Nucleus. 
OT   —  Optic  Thalamu.s. 


Arm 


Caudate  JVucleus 

Optic  Thalamus 

Z  enticular  Nucleus 


RptJ  JVucleus 


6  '-^Nucleus ^../. 

raiet 


Fillet 
J\/J  .\erve 

Crossed  J^yramidO-Z  TracT- 


Jirm 


Face 


CRUS    CEREBRI 

Lei'eL  of  5'''^  JVerve 

PONS 

Facial  jVeri/e 


MEDULLA 


JDirecl  Pyramidal  Trad 


SPINAL  CORD 


Fig.  66.     Diagrammatic  repre>;entation  of  the  Motor  Path  from  the  Corte-x 
to  the  Anterior  Horn  Cei].s. 


DISEASES   OF   THE   NERVOUS   SYSTEM        469 

The  Motor  Path.  The  cells  responsible  for  the  initiation 
of  all  YoluntarA'  movements  are  situated  in  the  cortex  of  the 
precentral  area  of  each  cerebral  hemisphere,  that  is  to  say, 
immediately  in  front  of  the  fissure  of  Rolando.  The 
characteristic  large  pyramidal  cells  of  Betz  are  only  found  in 
the  motor  area  of  the  cortex. 

In  front  of  the  precentral  area  is  the  intermediate  pre- 
central area  of  Campbell,  which  governs  the  more  highlv 
specialised  movements  of  the  body  as  opposed  to  the  crude 
movements  which  originate  in  the  precentral  area  proper. 
Both  the  precentral  and  the  intermediate  precentral  areas 
are  represented  on  the  mesial  as  well  as  on  the  superficial 
aspects  of  the  cerebral  hemispheres. 

The  nerve  fibres  originating  in  the  giant  Betz  cells  form 
the  pyramidal  tract  ;  they  pass  through  the  centrum  ovale 
to  become  part  of  the  corona  radiata,  and  converge  together 
into  a  fairly  compact  bundle  by  the  time  the  internal 
capsule  is  reached.  In  the  internal  capsule  they  occupy 
the  '•  genu  "  and  the  anterior  third  of  the  posterior  limb 
(Fig.  65). 

After  traversing  the  internal  capsule  the  p\Tamidal  tracts 
pass  through  the  crura  cerebri  and  ventral  aspect  of  the 
pons  to  form  the  pyramids  of  the  meduUa  oblongata,  but 
before  this  they  have  parted  company  with  the  fibres  for 
the  nuclei  of  the  third,  fifth,  sixth,  seventh,  and  tv.elfth 
cranial  nerves  and  with  some  to  the  nucleus  ambiguus  for  the 
motor  parts  of  the  ninth,  tenth,  and  eleventh  cranial  nerves. 
In  addition  to  this  some  fibres  are  connected  with  the  red 
nucleus,  the  thalamus,  and  the  pontine  nuclei,  whence 
arise  rubro-spinal,  ponto-spinal  and  thalamo-spinal  tracts, 
which  may  be  assumed  to  form,  under  certain  circumstances, 
alternative  routes  for  the  transmission  of  certain  motor 
impulses. 

At  the  pjTamids  of  the  medulla  the  pyramidal  tracts 
decussate  T\-ith  each  other  and  cross  to  the  other  side  to  form 
the  crossed  pyramidal  or  lateral  tracts  of  the  cord,  except 
for  a  small  number  which  are  contumed  down  the  anterior 
aspect  of  the  spinal  cord  on  the  same  side  to  form  the  direct 
p^Tamidal  tract  of  Turk.  The  fibres  of  the  direct  pyramidal 
tract,  however,  cros.-^  rid  the  anterior  commissure,  at  intervals 


470  MEDICAL   DIAGNOSIS 

all  the  way  down  the  cord  so  that  all  motor  fibres  are  ulti- 
mately crossed. 

Eventually  the  fibres  of  the  crossed  and  direct  pyramidal 
tracts  arborise  round  the  anterior  horn  cells  all  the  way 
down  the  cord. 

The  path  from  the  cerebral  cortex  to  the  anterior  horn  cells 
of  the  opposite  side  is  known  as  the  Upper  Motor  Neuron 
System,  and  any  lesion  of  this  path  produces  a  paralysis 
of  the  corresponding  muscles  of  the  opposite  side  of  the  body 
if  the  lesion  is  above  the  decussation  of  the  pyramids,  and  of 
the  muscles  on  the  same  side  if  the  lesion  is  in  the  cord. 

The  Loiver  Motor  Neuron  System  comprises  the  motor 
nerve  fibres  from  the  anterior  horn  cells,  or  their  bulbar 
analogues,  to  their  termination  in  the  muscles. 

The  Sensory  Path.  This  is  more  complex  and  less  fully 
worked  out  than  the  motor  path.  Certain  sensory  paths  cross 
before  reaching  the  brain,  but  others  are  homo-lateral. 
The  main  cortical  sensory  area  is  situated  in  the  post-central 
area  just  behind  the  fissure  of  Rolando,  and  the  individual 
localities  are  believed  to  correspond  fairly  closely  to  the 
adjacent  motor  areas. 

The  centres  for  Pain  and  Temperature  are  probably  rather 
posterior  to  those  just  described,  but  they  may  be  situated 
in  the  gyrus  fornicatus. 

Sensation  can  be  subdivided  into  three  main  groups — 
Protopathic,  Epicritic,  and  Deep. 

Protopathic  Sensation  includes  pain  and  extremes  of  heat 
and  cold. 

Epicritic  Sensation  comprises  light  touch,  localisation, 
tactile  discrimination,  and  slight  degrees  of  heat  and  cold. 

Deep  Sensation  includes  sense  of  passive  position  (com- 
prising impulses  from  joints,  muscles,  bones,  and  tendons), 
sense  of  pressure  or  contact,  and  sense  of  painful 
pressure . 

All  forms  of  sensation  enter  the  cord  through  the  posterior 
nerve  roots,  and  it  is  worthy  of  note  that  if  a  peripheral 
nerve  is  cut  there  is  a  greater  area  of  epicritic  sensory  loss 
than  of  protopathic. 

This  epicritic  overlap  is  less  marked  the  nearer  the  injury 
to  the  cord,  so  that  Head  considers  the  posterior  nerve  root 


CaudatP  AurleuA 

Optic    Thalamus 


Fillet  ..-. - 

Red  Nucleus 

To  Cerebellicm 

orpus  Restiforme 
FvlLet   

V  Merv/e  . 

r Spinal  Root  of.V 


s  Restiforme  

tio  ^ect it  u Icxris  _ 
/  Root  of  t^ 


//  7o  Cerebellum 


f  Go  leers'  Trez  ct   - 
Ut 


'eus  GrciCLlts  - . 

?us  Cunecztus 

:i I  Root  of  V 

Y  Cerehnllar  Trad 
of  Goners  Trcict  ■  -  • 
FiUet      


irt Of    Tactt to  Sense  (U/xrossec/j 
iJoint     Spni>e  do 

KmaeiUtetir  i>eni,f     do 


Face 


CPUS   CEREBRI 


PONS 


Level  of  VyVerve 


PONS 


Level  of  S^J^erve 


£ciuilihi'iiirn 
(Direct  Cerebellnr  Trc 

MEDULLA 


Bulk   of  laclilc  Sc//.si'  (Cros 
Trmperatitre  i  Pair, 


SPINAL  COR 


Ecfuilibrutni  ((finrnss 


lM(i.  f)7.     DiaMr.MniiiMtlc  rcpiTsc-ntatioii  of  tlir  p.itli<  taken  l._v  llir  S.iisdiy  Impnis 

Cord  and  Uraiii 


pnlsos  111 


DISEASES   OF  THE   NERVOUS   SYSTEM       471 

to  be  the  unit  of  protopathic  sensibility  and  the  peripheral 
nerve  to  be  the  unit  of  epicritic  sensibility. 

The  fibres  for  deep  sensation  run  with  the  motor  nerves, 
though,  of  course,  they  enter  the  cord  by  the  posterior  root. 
The  cells  of  origin  of  the  sensory  spinal  nerves  are  in  the 
posterior  root  ganglia.  On  entering  the  cord  by  the  posterior 
root  the  sensory  fibres  may  behave  as  follows  : — 

(a)  The  long  fibres  pass  into  the  columns  of  Burdach  and 
Goll  and  run  up  in  these  columns  homo-laterally  to  arborise 
round  cells  in  the  cuneate  and  gracile  nuclei  of  the  medulla 
respectively.  The  lowest  spinal  fibres  get  squeezed  more  and 
more  towards  the  mid-line  by  the  fibres  which  enter  later, 
so  that  the  lower  spinal  fibres  form  the  column  of 
Goll  and  the  upper  spinal  fibres  form  the  column  of 
Burdach.  This  differentiation  usually  results  in  those  fibres 
from  below  the  fourth  dorsal  segment  forming  Goll's 
column. 

The  cells  of  the  gracile  and  cuneate  nuclei  give  off  fresh 
fibres,  which  decussate  with  their  fellows  of  the  opposite 
side  in  the  fillet  and  are  continued  as  the  mesial  fillet  through 
the  medulla  and  pons  to  arborise  round  cells  in  the  ventral 
aspect  of  the  optic  thalamus. 

From  the  optic  thalamus  the  third  and  last  relay  starts 
and  the  fibres  run  through  the  posterior  part  of  the  posterior 
limb  of  the  internal  capsule  to  the  post-central  cortical 
sensory  area. 

The  following  sensory  impulses  travel  in  the  manner 
just  described  : — 

Sense  of  Passive  Position. 
Sense  of  Tactile  Discrimination. 
Part  of  Ordinary  Touch. 
Part  of  Localisation. 

Before  setting  out  on  their  upward  course  these  long  fibres 
give  off  a  branch  which  passes  downwards  for  a  short 
distance  in  the  posterior  horn  of  the  same  side  as  the  comma 
tract  of  Schultzo. 

(6)  The  short  fibres  arborise  round  cells  in  the  posterior 
horn  immediately  on  entering  the  cord  ;  from  these  cells 
fibres  are  given  off  which  may  cross  immediately  to  the 


472  MEDICAL   DIAGNOSIS 

other  side  of  the  cord  by  the  posterior  commissure  or  which 
may  run  a  variable  distance  in  the  posterior  columns  before 
thus  crossing.  In  either  event  when  crossed  the  fibres 
run  up  the  cord  as  the  spino-thalamic  tract  in  close  apposition 
to  the  ventral  cerebellar  tract,  but  leave  this  tract  when  it 
passes  into  the  superior  cerebellar  peduncle  and  are  themselves 
continued  straight  to  the  cells  in  the  ventral  aspect  of  the  optic 
thalamus.  From  here  fibres  are  given  off  which  run  through 
the  internal  capsule  to  the  appropriate  cortical  sensory 
areas. 

The  sensory  impulses  which  adopt  this  route  are  : — 

Sense  of  Pain  and  painful  pressure. 

Sense  of  Heat  and  Cold  both  moderate  and  extreme. 

Most  of  the  Sense  of  Touch. 

Part  of  the  Sense  of  Localisation. 

(c)  The  medium  fibres  take  one  of  two  courses  : — (i.)  To 
the  cells  of  Clarke's  column  on  the  same  side,  from  which  are 
given  off  the  fibres  forming  the  dorsal  or  direct  cerebellar 
tract  of  Flechsig.  The  direct  cerebellar  tract  runs  up  on 
the  same  side  through  the  medulla  and  pons  to  enter  the 
cerebellum  via  the  restiform  body  ;  these  fibres  terminate 
on  the  dorsal  aspect  of  the  vermis  or  middle  lobe  of  the 
cerebellum,  (ii.)  To  certain  cells  in  the  posterior  horn,  from 
which  arise  the  fibres  forming  the  ventral  cerebellar  tract 
of  Gowers.  This  runs  up  on  the  same  side  of  the  cord  to 
enter  the  cerebellum  through  its  superior  peduncle  and 
terminates  on  the  ventral  aspect  of  its  middle  lobe. 

Since  the  functions  of  the  cerebellum  are  largely  connected 
with  equilibration  and  co-ordination  it  is  probable  that 
certain  impulses  from  muscles,  bones,  joints,  etc.,  travel 
in  these  columns  and  enable  the  cerebellum  to  establish 
equilibration  and  stability. 

(d)  Some  fibres  entering  by  the  posterior  root  run  straight 
across  to  arborise  round  certain  anterior  horn  cells  of  the 
same  side  and  so  complete  the  various  segmental  reflex  arcs. 

It  is  quite  impossible  in  the  present  state  of  our  knowledge 
to  be  didactic  as  to  the  various  sensory  paths.  That  the 
above  description  is  probably  correct  for  the  majority  of 
cases  is  shown  by  the  clinical  phenomena  which  are  seen 


DISEASES   OF   THE   NERVOUS   SYSTEM        473 

after  hemisection  of  the  cord  (Brown-Sequard's  paralysis) 
as  shown  by  the  following  table  : — ■ 

On  the  Side  of  the  Lesion.  On    the    Side    Opposite    to    the 

Lesion. 

Motor  paralysis.  No  motor  paralysis. 

Generally     no     impairment     of  Generally  impairment  of   touch, 

touch,      Ught      pressure      or  light    pressure    or    cutaneous 

cutaneous  localisation.  localisation. 

Pain  and  temperature  sensations  Abolition  of  pain,   temperature 

normal ;  painful  pressure  nor-  and    painful    pressure    sensa- 

mal.  tions. 

Impairment      of      tactile      dis-  Persistence  of  sense  of  passive 

crimination     and     sense     of  position      and      tactile      dis- 

passive  position.  crimination. 

At  the  same  time  the  above  phenomena  are  not  constantly 
found  when  the  lesions  would  suggest  that  they  ought  to  be 
present,  so  that  the  preceding  remarks  as  to  the  sensory 
paths  must  only  be  regarded  as  a  sound  working  hyp<)thesis 
until  more  accurate  knowledge  can  be  obtained. 

The  Cerebellum  does  not  initiate  impulses  on  its  own 
account  and  appears  to  be  chiefly  concerned  with  the  pre- 
servation of  equilibrium  in  both  standing  and  walking.  For 
this  purpose  stimuli  are  constantly  passing  to  the  cerebellum 
from  the  periphery  conveying  impressions  of  alteration  in 
the  position  of  any  particular  part  of  the  body  in  relation 
to  its  environment.  These  afferent  stimuli  call  forth  corre- 
sponding efferent  impulses  regulating  the  proper  co-ordina- 
tion of  certain  muscle  groups,  and  generally  determining 
the  strength  of  the  nervous  impulses  passing  to  the  muscles 
concerned  from  the  cerebral  cortex. 

The  afferent  impulses  to  the  cerebellum  are  conveyed  from 
the  periphery,  and  mostly  from  the  muscles  of  the  back  and 
extremities,  to  the  cerebellum  by  way  of  the  spino-cerebeliar 
tracts  and  the  columns  of  Flechsig  and  Gowers,  which  are 
homo-lateraP  and  enter  the  cerebellum  I'id  the  rcstiform 
body  and  the  superior  peduncle  respectively  ;  they  terminate 
respectively  on  the  dorsum  and  venter  of  the  vermis  or 
midfllo  lobe  of  the  cerebellum.  There  are  also  fibres 
running  from  the  olive  to  the  vermis. 

'  Gower's  column  may  receive  certain  fibres  from  the  cells  of  the  contra- 
lateral posterior  horn. 


474  MEDICAL   DIAGNOSIS 

Another  cerebellar  path  is  by  way  of  the  vestibular  nerve, 
by  means  of  which  impulses  from  the  ampulla,  utricle  and 
saccule  of  the  internal  ear  are  conveyed  to  the  vestibular 
nucleus  of  the  cerebellum,  thence  to  Deiter's  nucleus,  and 
finally  to  the  vermis.  The  sensations  of  perception  of  space 
and  proper  orientation  depend  largely  on  an  intact  vestibular 
path.  The  nuclei  of  the  ocular  muscles  also  have  free 
communication  with  Deiter's  nucleus,  and  form  in  this  way  a 
supplementary  vestibular  system,  without  which  our  power 
of  estimating  distances  would  be  very  deficient. 

The  cerebellar  tracts  just  described  (Fig.  68)  should  be 
considered  as  the  afferent  limbs  of  a  most  important  reflex 
system.  The  efferent  paths  of  the  cerebellar  reflex  system 
are  as  follows  : — 

(i.)  From  Deiter"s  nucleus  (which  thus  appears  to  be  both 
motor  and  sensory)  via  the  dorsal  longitudinal  bundle  with 
the  oculo-motor  nuclei. 

(ii.)  From  Deiter's  nucleus  arises  the  vestibulo-spinal 
tract,  which  runs  through  the  medulla,  down  the  periphery 
of  the  spinal  cord  on  the  same  side  for  its  entire  length. 

Presumably  this  tract  is  the  route  adopted  by  the  control- 
ling impulses  from  the  cerebellum  to  the  homo-lateral  trunk 
and  limb  muscles. 

(iii.)  From  the  corpus  dentatum  via  the  middle  cerebellar 
peduncle  fibres  pass  to  the  pontine  nucleus  and  tegmentum 
cruris  of  the  opposite  side. 

(iv.)  From  the  corpus  dentatum  arises  the  brachium 
conjunctivum,  which  passes  through  the  superior  peduncle 
to  the  tegmentum,  where  it  decussates  and  terminates  in  the 
red  nucleus  and  optic  thalamus  of  the  opposite  side. 

It  is  possible  that  by  means  of  these  last  two  paths  the 
cerebellum  regulates  the  synergic  action  of  the  motor 
impulses  passing  down  the  ponto-spmal,  rubro-spinal  and 
thalamo-spinal  tracts  ;  it  is  also  possible  that  there  is  an 
indirect  connection  between  one  cerebellar  lobe  and  the 
opposite  cerebral  cortex  via  the  brachium  conjunctivum, 
the  optic  thalamus,  the  internal  capsule,  and  the  centrum 
ovale. 

The  decussation  of  the  fibres  from  the  corpus  dentatum 
to  the  red  nuclei  does  not  affect  the  homo-lateral  influence 


PONS 


Red  Nucleus 


y£f/rfiAL 
_  ASP£CT 

^„     --,^         OF 


/v^ 

■~.J__Py     f  ^v./"^ 

m 

^Ml 

'^eiiibulOi 

DORSAL 

"— —  — 

w 

^S 

<i~^Mucleus 

ASPECT 

'  # 

/^\ 

""^K*?-^ 

OF 

Reitiform  ,■' 

r     X 

,' 

v^^^    7" 

l^£PMIS 

Body 

-Rubro-Spinat  Tract 
I'estibuloSpinci/  Tract 


Dorsal  Cerebellar 
or  Tract  of/''lechsip 


■  -  Cov^e'rs  Tract 
Vest ihulo--'^pt rial  Tract 


Flu.  G8. — Ciagramiuatic  repri-sfiitatioii  i)f  tht-  Main  CVrcbillar  connections. 


DISEASES   OF  THE   NERVOUS   SYSTEM        475 

of  the  cerebellum  on  the  muscles  of  the  trunk  and  limbs, 
because  the  rubro-spinal  tract  (Monakow's  bundle)  itself 
decussates  soon  after  its  inception  and  these  two  decussa- 
tions naturally  neutralise  each  other. 

These  anatomical  facts  will  be  appreciated  more  readily 
if  they  are  considered  in  conjunction  with  Figs.  65 — 68. 

II.  Reflex  Actions.  In  addition  to  the  cerebellar  reflexes 
considered  in  the  last  section  three  types  of  reflex  may  be 
distinguished  :— 

(i.)  Superficial,  obtained  by  stroking  or  light  scratching 

of  the  skin  ; 

(ii.)  Deep  reflexes,  obtained  by  tapping  a  tendon  which 

is  in  a  state  of  slight  tension  ;   and 

(iii.)  Organic    reflexes,    which    comprise    such    acts    as 

swallowing,  micturition,  defgecation,  and  parturition. 
These  reflex  actions  take  place  quite  automatically  under 
certain  circumstances  and  can  occur  independently  of/ any 
action  of  the  brain,  though  such  organic  reflexes  as  swallowing 
or  micturition  become  more  or  less  subject  to  cerebral 
control  in  process  of  evolution  and  education.  Furthermore, 
the  deep  reflexes  are  subject  to  constant  inhibitory  impulses 
from  the  brain,  so  that  their  vigour  is  modified  in  certain 
brain  and  cord  lesions  which  do  not  actually  involve  the 
reflex  path  concerned. 

The  superficial  reflexes  are  also  influenced  by  the  brain, 
but  the  nature  of  the  cerebral  control  is  uncertain. 

The  anatomical  path  for  the  performance  of  a  spinal 
reflex  consists  of  an  afferent  limb  by  which  the  stimulus  is 
conveyed  to  the  cord  vid  the  posterior  nerve  root,  a 
connecting  fibre  which  consists  in  the  arborisation  of  one 
of  the  short  posterior  root  fibres  round  the  corresponding 
anterior  horn  cells  of  the  same  spinal  segment,  and  an 
efferent  limb  by  which  the  responsive  impulse  is  conveyed 
to  the  muscle  concerned.  The  controlling  or  inhibitory 
impulse  for  deep  reflexes  from  the  cerebrum  travels  in  the 
lateral  pyramidal  tract  {vide  Fig.  69). 

Since  even  in  sleep  the  majority  of  the  muscles  are  never 
absolutely  flaccid,  there  is  a  necessity  for  a  constant  series 
of  afferent  impulses  from  the  muscles  requisitioning  efferent 
impulses  to  regulate  the  muscle  tone.     This  tonic  path  for 


476  MEDICAL   DIAGNOSIS 

different  muscles  is  identical  with  the  reflex  path  just 
described,  and  the  deep  reflexes  are  thought  to  depend 
largely  on  the  state  of  muscular  tonus. 

The  following  reflexes  are  the  ones  most  usually  examined  : 
A.  The  Superficial  Reflexes  : — 

Corneal  and  Conjunctival.  Blowing  upon  or  gently 
touching  the  cornea  or  conjunctiva  causes  the  eyelid  to 
shut. 

Palatal.  Touching  the  soft  palate  causes  the  uvula 
to  be  drawn  up. 

Pharyngeal.  Touching  the  posterior  pharyngeal  wall 
causes  the  throat  muscles  to  contract. 

Epigastric  and  Abdominal.  Stroking  the  skin  below 
the  rib  margins  and  stroking  the  outer  border  of  the 
rectus  abdominis  causes  contraction  of  the  abdominal 
muscles  in  the  quadrant  tested. 

Scapular.  Stroking  the  skin  between  the  shoulder 
blades  causes  the  scapular  muscles  to  contract. 

Anal.  Scratching  the  perinseum  causes  the  sphincter 
ani  to  contract. 

Cremasteric.  Stroking  the  skin  over  Scarpa's  triangle 
causes  the  testicle  to  retract. 

The  Plantar  Beflexes.  To  elicit  the  plantar  response 
successfully  it  is  necessary  to  have  the  leg  somewhat 
everted  at  the  hip  and  flexed  at  the  knee  with  the  ankle 
completely  relaxed  ;  the  foot  must  be  warm  and  dry. 
The  skin  of  the  sole  is  now  stroked  rather  firmly  (as  with 
a  penholder)  along  its  outer  border. 

In  health  there  is  flexion  of  the  toes,  including  the  big 
toe,  and  a  tendency  to  inversion  of  the  foot. 

In  Lesions  of  the  Upper  Motor  Neuron  and  in  infants 
who  have  not  yet  walked  a  totally  different  response 
takes  place ;  the  foot  tends  to  be  everted  and  the  great 
toe  becomes  extended  (Babinski's  phenomenon). 

The  essential  part  of  this  test  is  the  behaviour  of  the 
great  toe ;  when  properly  performed  it  is  an  invaluable 
aid  to  diagnosis. 

Even  apart  from  the  plantar  reflex  the  diagnostic  value 
of  the  superficial  reflexes  is  considerable,  though  perhaps  not 
so  great  as  in  the  case  of  the  deep  reflexes. 


DISEASES   OF   THE  NERVOUS   SYSTEM       477 

Exaggeration  of  superficial  reflexes  does  not  imply  organic 
disease. 

Absence  or  great  depression  of  the  superficial  reflexes  is 
found  in  upper  motor  neuron  lesions  and  often  in  cases  of 
increased  intra-cranial  tension,  but  is  very  rarely  if  ever 
seen  in  functional  disease. 

Disease  of  the  ner^^e  roots  may  cause  absence  of  all  reflexes 
for  the  segments  concerned. 
B,  The  Deep  Reflexes  : — 

The  Knee  Jerk.  One  leg  is  crossed  over  the  other  and 
allowed  to  hang  quite  loosely  ;  the  patellar  tendon  is  now 
struck  smartly  towards  its  inner  edge — the  quadriceps 
muscle  contracts  and  the  foot  is  kicked  up  in  consequence. 
This  test  may  be  reinforced  by  supporting  the  toes  of 
the  hanging  foot  with  the  hand  of  the  examiner  or  by 
instructing  the  patient  to  shut  his  eyes  and  clench  both 
hands  as  tightly  as  he  can.  / 

Reinforcement  should  always  be  employed  before  the 
knee  jerk  is  said  to  be  absent. 

The  Achilles  Jerk.  The  patient  is  asked  to  kneel  on 
a  chair  or  couch,  with  his  feet  projecting  over  the  edge  ; 
the  tendon  Achilles  is  smartly  struck,  and  the  calf- 
muscles  contract  and  extend  the  foot  at  the  ankle- 
joint. 

Supinator  Jerk.  The  elbow  is  flexed  to  about  120° 
and  the  arm  supported  in  this  position  with  the  hand 
hanging  down.  The  back  of  the  radius  is  now  struck 
just  above  the  styloid  process  and  the  hand  is  jerked 
slightly  upwards. 

Triceps  Jerk.  The  elbow  is  flexed  to  a  right  angle  and 
the  arm  supported  ;  the  triceps  tendon  is  struck  above 
the  olecranon  process,  and  the  triceps  muscle  can  be  seen 
and  felt  to  contract. 

Clonus.  This  occurs  when  there  is  great  exaggeration 
of  deep  reflexes  due  to  lack  of  cerebral  inhibition,  as  in 
an  upper  motor  neuron  lesion. 

Pseudo-clonus  may  occur  in  hysteria. 
Ankle  Clonus  is  elicited  by  placing  the  leg  in  the  position 
described  for  the  plantar  reflex  and  suddenly  dorsiflexing 
the  foot,  which  has  been  grasped  round  the  toes. 


478  MEDICAL  DIAGNOSIS 

Patellar  Clonus  is  elicited  by  extending  the  leg  so  that 
the  patella  moves  freely,  and  then  suddenly  pushing  the 
patella  downwards  so  as  to  stretch  the  quadriceps  tendon. 
The  deep  reflexes  are  never  entirely  absent  in  health  ; 

such  a  condition  must  mean  a  lesion  somewhere  in  the  reflex 

arc  or  in  the  muscles  themselves. 

Exaggeration  of  the  deep  reflexes  occurs  in  hysteria,  but 

is  significant  of  upper  motor  neuron  lesion  if  it  is  accompanied 

by  spasm,  if  it  is  unilateral,  or  if  it  is  only  present  below 

a  certain  level. 

III.  The  Vaso-motor  System.  The  vaso-constricting 
fibres  arise  in  the  lateral  sympathetic  ganglia,  while  vaso- 
dilating fibres,  when  present,  are  in  the  other  ganghon 
systems  incorporated  in  the  sympathetic  nervous  system. 

The  constricting  fibres  travel  in  the  ordinary  mixed  nerves 
and  reach  these  structures  in  the  grey  rami  communicantes 
which  run  from  the  sympathetic  ganglia  to  the  segmental 
nerves.  There  are,  however,  spinal  vaso-constricting  cells 
in  the  centre  of  the  anterior  horn  cells,  and  from  these  are 
given  oft'  white  rami  communicantes  which  run  to  the  lateral 
sympathetic  ganglia  {vide  Fig.  69). 

The  spinal  vaso-motor  centres  are  controlled  by  a  vaso- 
motor centre  in  the  medulla,  and  probably  this,  in  turn,  is 
under  the  influence  of  some  part  of  the  precentral  cortex. 

The  fibres  from  the  medullary  centre  to  the  spinal  cell- 
stations  run  in  the  lateral  pyramidal  tracts. 

IV.  Cerebral  Localisation  and  Blood  Supply.  The  cortical 
localisation  of  the  various  functions  of  the  brain  is  not  yet 
completely  worked  out.  A  consideration  of  the  previous 
pages,  in  conjunction  with  Fig.  70,  will  assist  in  mastering 
what  is  known  up  to  the  present  on  this  subject. 

The  Blood  Supply  of  the  Brain.  A  knowledge  of  the 
blood  supply  of  the  brain  is  of  importance  in  view  of  the  fact 
that  vascular  lesions  are  so  common  in  the  cerebral  blood- 
vessels. 

The  circle  of  Wilhs  is  situated  in  the  inter-peduncular 
space  at  the  base  of  the  brain.  The  circle  is  formed  behind 
by  the  two  posterior  cerebral  arteries  which  are  terminal 
branches  of  the  basilar  artery  (formed  by  the  union  of  the 
two  vertebral  arteries).     In  front  the  two  internal  carotid 


a8i9V80«i}    ni   JbioO 


t   io    noi  1 


{>fjfini/n6-iS£iQ — Md    .oi'i 


llii^l   "iuJ 


IfiloJfcl     J 


hilA  ,i-jy.'jll^  - 


a  .A 
o   .a 

7      .0 

a  .a 
;a  .a 
.0   :i 

.) 

//I 

i  0  aia  »9idd  od  i 
mjM     .S  baa  I 
i  i"!     .!•  baa  «S 
'n  ioaii 


XiiluL-jul    -jxIJ     illu'il    l,;lii 


iaIIo<IoT 


f  xmo^  oi  :gniog  n0iuloo-n"»o 


Joaii  lAlIatl 


r[„lMl    1.,   t^i 


■T     .nf>  hrrr  ft 


lO)   -Jflt 

,:ltl      i 

M.n  OJ 

:i  bna  i(ii 

If 

.d>i.i,,....   . 

u'Giy  V 
Fig.  69.— Diagrammatic  representation  of  the  Spinal  Cord  in  transverse 
section  at  the  level  of  the  eighth  dorsal  vertebra,  showing  the  principal 
tracts,  the  paths  taken  by  the  sensory  fibres  entering  by  the  posterior 
nerve  root,  the  reflex  path  for  tendon  reflexes,  and  the  vasomotor  path 
{vide  p.  478),  etc. 

The  tracts  are  seen  on  the  left  of  the  figure. 

A.  Direct  pyramidal  tract. 

B.  Crossed  pyramidal  or  lateral  tract. 

C.  Ventral  cerebellar  tract  of  Gowers. 

D.  Dorsal  cerebellar  tract  of  Flechsig. 

E.  Burdach's  column. 

F.  GoU's  column. 

G.  Comma  tract. 

H.  Vestibulo-spinal  tract. 

I.  Clark's  column. 

K.  Lissauer's  tract. 

L.  Spino -Thalamic  tract. 

The  fibres  are  chiefly  on  the  right  of  the  figure. 

I  and  2.     Motor  nerve  fibres  leaving  the  anterior  horn  cells. 

2a  and  4.     Fibres  conveying  cerebral  imj)ulses  to  1  and  2  via  the  lateral 
tract  and  the  direct  pyramidal  tract  respectively. 

3.  Vasomotor  fibre   running  from   the   medulla   in   the   lateral   tract   to 

control  (7). 

4.  [Vide  supra). 

5.  Fibres  from  Clarke's  cell-column  going  to  form  the  direct  cerebellar 

tract. 
6  and  6a.     The  motor  and  sensory  limbs  respectively  for  the  ordinary  deep 

reflex  arc. 
.7.     The  white  ramus  communicans  which  leaves  in  the  anterior  nerve  root 

and  runs  to  the  sympathetic  gangUon  X. 

8.  Grey  ramus  communicans  running  from  the  sympathetic  ganglion  X  to 

the  mixed  nerve. 

9.  The  path  for  temperature,  most  of  touch,  and  pain  sensations  crossing 

the  cord  to  join  the  contra -lateral  sj)ino-thalamic  tract. 
10  and  10a.     Equihbration  fibres  running  to  the  ventral  cerebellar  tract. 

II  and  12.     Fibres  for  joint  and  muscle  sense,  etc.,  rimning  to  the  columns 

of  Goll  and  Burdach. 


Ki(!.  m. 


1%0X  Ik. 


DISEASES   OF  THE   NERVOUS   SYSTEM       479 

arteries  divide  into  the  middle  cerebral  arteries  and  the 
anterior  cerebral  arteries. 

Joining  the  two  anterior  cerebral  arteries  is  the  anterior 
communicating  artery,  and  each  posterior  cerebral  artery 
is  joined  with  the  termination  of  the  corresponding  internal 
carotid  artery  by  a  posterior  communicating  artery. 

Each  cerebral  artery  supplies  both  superficial  and  deep 
aspects  of  the  brain. 

The  Anterior  Cerebral  Artery  supplies  the  external  surface 
as  far  backwards  as  the  middle  of  the  parietal  lobe  and  as 
far  do^vnwards  as  the  superior  frontal  sulcus  ;  mesially  it 
runs  as  far  backwards  as  the  parieto-occipital  fissure  and 
includes  the  corpus  callosum  and  gyrus  fornicatus.  The 
deep  branches  of  the  anterior  cerebral  artery  supply  the 
anterior  limb  of  the  internal  capsule  and  the  anterior  parts 
of  the  lenticular  and  caudate  nuclei,  as  well  as  the  floor  of 
the  third  ventricle.  ' 

The  Middle  Cerebral  Artery  supplies  the  external  surface 
from  the  superior  frontal  sulcus  to  the  anterior  occipital 
sulcus,  while  it  extends  downwards  to  the  second  temporal 
sulcus.  It  gives  no  branches  to  the  mesial  surface.  The 
deep  branches  of  the  middle  cerebral  artery  supply  the 
remainder  of  the  caudate  and  lenticular  neucleus  ;  the 
middle  part  of  the  optic  thalamus  (lenticulo-optic  artery), 
the  centrum  ovale,  the  posterior  limb  of  the  internal  capsule, 
the  external  capsule,  and  the  outer  and  upper  haK  of  the 
optic  radiations. 

The  Posterior  Cerebral  Artery  supplies  the  rest  of  the 
external  surface  of  the  brain  except  the  uncinate  lobe,  which 
is  supphed  by  the  anterior  choroidal  artery,  so  that  mesially 
it  runs  up  to  the  anterior  cerebral  artery  and  externally  up 
to  the  middle  cerebral  artery. 

The  deep  branches  of  the  posterior  cerebral  artery  supply 
the  posterior  half  of  the  optic  thalamus,  the  pulvinar,  the  red 
nucleus,  and  the  lower  inner  half  of  the  optic  radiations. 

The  Anterior  Choroidal  Artery  is  given  ofiE  from  the  internal 
carotid  artery  just  before  its  bifurcation  ;  it  supplies  the 
uncinate  lobe  superficially  and,  deeply,  the  anterior  part 
of  the  optic  thalamus,  the  corpora  quadrigemina,  the 
internal  geniculate  bodies,   most   of   the  fornix,   and   the 


480  MEDICAL  DIAGNOSIS 

posterior  part  of  the  posterior  Hmb  of  the  internal 
capsule. 

The  Cerebellum  is  supplied  by  three  vessels — superior, 
middle,  and  inferior  cerebellar  arteries,  the  two  former 
arising  from  the  basilar  and  the  last  from  the  vertebral  artery. 

The  Pons  and  Medulla  are  supphed  by  the  numerous 
branches  of  the  basilar  artery. 

It  is  important  to  remember  that  the  terminal  branches 
of  the  cerebral  arteries  do  not  anastomose  with  their  fellows 
from  the  same  trunk,  though  terminals  from  the  middle 
cerebral  anastomose  to  some  extent  with  terminals  from  both 
anterior  and  posterior  cerebral  arteries  where  these  abut. 

Further,  the  superficial  and  deep  branches  in  no  place 
anastomose  with  each  other. 

V.  Electrical  Reactions  of  Muscles.  A.  In  Health. 
Faradic  stimulation  causes  a  brisk  and  sustained  contraction. 
The  electrode  should  be  placed  as  near  as  possible  to  that 
part  of  the  muscle  into  which  its  nerve  passes. 

Galvanic  stimulation  causes  a  single  contraction  when  the 
current  is  made  or  broken,  but  no  contraction  while  the 
current  is  passing.  The  force  of  the  contraction  varies 
according  to  whether  the  anode  or  the  kathode  is  applied  to 
the  muscle  and  also  according  to  whether  the  current  is 
made  or  broken. 

The  magnitude  of  the  healthy  response  is  represented  as 
follows  : — 

KCOACC:    AOOKOC, 

where  K  =  Kathode,  A  =  Anode,  CO  =  closing  contrac- 
tion, and  OC  =  opening  contraction. 

Stimulation  of  the  nerve  leading  to  the  muscle  also  causes 
a  contraction  both  with  faradism  and  galvanism. 

B.  In  Lesions  of  the  Lower  Motor  Neurons  the  so-called 
reaction  of  degeneration  takes  place — that  is  to  say,  the 
response  to  faradism  becomes  diminished  or  lost  and  the 
response  to  galvanism  becomes  sluggish  instead  of  brisk, 
and  in  addition  the  qualitative  arrangement  of  the  responses 
becomes  notably  altered.     For  example  : — 

AGO  becomes  equal  to  or  greater  than  KCC  and  KOC 
becomes  greater  than  AOC. 


DISEASES   OF   THE    NERVOUS   SYSTEM        481 

In  extreme  cases  no  response  to  either  faradisin  or 
galvanism  can  be  elicited,  whether  the  current  is  applied 
to  the  nerve  or  to  the  muscle.  More  usually  the  nerve 
loses  its  power  of  response  completely  while  the  galvanic 
reactions  of  the  iJiuscles  show  the  above  qualitative 
changes. 

It  is  worthy  of  note  that  in  ordinary  cases  the  openimj 
contractions  for  the  galvanic  current  require  so  strong  a 
current  that  so  much  pain  is  caused  as  to  negative  the  use 
of  this  portion  of  the  test. 

VI.  Evidence  of  Lesions  in  the  Motor  Path.  A.  Lesions 
of  the  Upper  Motor  Neuron  System  produce  a  spastic  motor 
paralysis  for  all  voluntary  muscles  below  the  lesion,  the 
affected  muscles  being  on  the  opposite  side  of  the  body  if 
the  lesion  is  above  the  decussation  of  the  pyramids. 

At  the  same  time  the  deep  reflexes  for  the  affected  area 
are  increased  and  the  superficial  reflexes  are  abolishejd  or 
very  much  diminished  ;  the  plantar  reflex  gives  an  extensor 
response  and  clonus  can  be  elicited.  The  muscles  are  rigid 
and  stiff,  but  there  is  no  real  loss  of  muscle  power,  no  wasting, 
anfl  no  reaction  of  degeneration,  because  the  lower  motor 
neurons  are  intact. 

B.  Lesions  of  the  Lower  Motor  Neuron  System  produce  a 
flaccid  paralysis  of  the  muscles  supplied  from  the  affected 
anterior  horn  cells  or  by  the  damaged  motor  nerve. 

All  reflexes  are  abolished  in  the  affected  area,  the  muscles 
waste,  there  is  marked  reaction  of  degeneration,  and  often 
trophic  change. 

N.B.  The  extensor  plantar  response  is  the  most  valuable 
evidence  of  an  organic  lesion  involving  the  upper  motor 
neuron  system.  It  is  not  met  with  in  functional  disease 
and  cannot  easily  be  maintained  by  malmgerers.  The  only 
circumstances  other  than  organic  disease  of  the  upper 
motor  neuron  path  in  which  an  extensor  plantar  response 
may  occui-  are  : — 

(i.)  Anterior  ])()li()mvelitis,  picking  out  only  the  cells  for 
the  flexoi-  juusciles  of  the  toes,  so  that  if  any  plantar 
response  occurs  it  must  be  extensor.  This  condition 
must  be  so  rare  as  to  be  negligible  clinically.  Obvious 
poliomyelitis  elsewliere  Avith  an  extensor  response  might 
M  I).  31 


482  MEDICAL   DIAGNOSIS 

suggest  the  above  explanation,  provided  that  there  was 
no  other  evidence  of  upper  motor  tract  involvement. 

(ii.)  Coma  and  even  sleep  have  been  reported  as  being 
occasionally  associated  with  an  extensor  plantar  response. 
Much  more  usually,  we  feel  sure,  is  there  an  absence  of 
all  response  under  such  ch'cumstances,  and  we  have  not 
observed  a  constant  extensor  response  in  any  such  case 
when  the  reflex  has  been  repeatedly  examined  in  the 
proper  manner  {vide  p.  476). 

A  lesion  of  the  cord  above  the  centres  for  the  reflex 
emptying  of  the  bladder  and  rectum  (S  3 — S  4)  usually 
entails  involuntary  micturition  as  soon  as  the  viscus  is 
sufficiently  distended  by  urine  to  excite  the  reflex  act. 
The  rectum  does  not  behave  in  quite  the  same  manner, 
since  there  is  generally  constipation  owing  to  reflex  spasm 
of  the  sphincter. 

When  the  lesion  is  in  the  sacral  region  and  involves  the 
centres  tliemselves  there  is  usually  permanent  incontinence 
of  both  urine  and  faeces,  the  bladder  and  rectum  merely 
serving  as  open  passage-ways  ;  not  infrequently,  however, 
there  is  sufficient  elasticity  in  the  neck  of  the  bladder  to 
permit  of  considerable  distension  before  overflow  dribbling 
away  takes  place  (retention  with  overflow). 

The  sexual  ajjparatus  (S  1 — S  4)  behaves  in  an  analogous 
way  ;  lesions  above  the  centre  often  produce  more  or  less 
priapism  and  a  tendency  for  an  exaggerated  effect  from 
trifling  stimuli,  while  lesions  involving  the  centre  cause  com- 
plete impotence. 

VII.  Evidence  of  Lesions  in  the  Sensory  Paths.  A.  A 
posterior  root  lesion  diminishes  all  forms  of  sensory  percep- 
tion for  the  region  concerned.  Since,  however,  no  area  sends 
its  sensory  impulses  exclusively  to  one  posterior  nerve  root, 
complete  loss  of  all  sensation  implies  a  lesion  of  more  than 
one  nerve  root  (provided,  of  course,  that  the  distribution 
of  sensory  disturbance  is  segmental  and  not  attributable 
to  a  damaged  peripheral  sensory  nerve). 

B.  Ataxia  and  astereognosis  are  present  m  posterior 
root  lesions  provided  that  a  sufficiently  extensive  area  is 
involved  to  permit  of  their  demonstration. 

C.  Complete  loss  of  tactile  sensation  implies  a  lesion  of — 
(i.)  A  peripheral  nerve  ; 


DISEASES    OF   THE   NERVOUS   SYSTEM        483 

(ii.)  Two  or  more  posterior  nerve  roots,  or  root  zones 
within  the  cord  ;    or 

(ui.)  Both  homolateral  posterior  and  contra-lateral 
spino -thalamic  columns  in  the  cord. 

D.  Loss  of  pain  and  heat  sensation  implies  as  a  rule  a 
les  on  of  the  grey  matter  or  of  the  contra-lateral  spino- 
thalamic tract,  provided  the  posterior  roots  and  peripheral 
nerves  are  intact. 

E.  Ataxia  of  cerebellar  type  occurs  in  lesions  of  the  ascend- 
mg  cerebellar  tracts  or,  of  course,  of  the  cerebellum  itself. 

F.  Before  complete  destruction  of  the  cells  and  fibres 
concerned  m  a  lesion  of  the  sensory  paths  takes  place 
irritation  phenomena  often  become  manifest.  These  take 
the  form  of  pain,  numbness,  tingling,  itching,  etc.,  and  are 
referred  to  the  segmental  area  in  the  case  of  posterior  root 
lesions  and  to  the  area  of  peripheral  supply  in  the  case  of 
a  peripheral  nerve — that  is  to  say,  to  the  region  of  the  sensory 
end  organs  of  the  damaged  fibres. 

VIII.  Segmental  Distribution.  As  an  aid  to  regional 
diagnosis  it  is  necessary  to  be  familiar  with  the  cutaneous 
distribution  of  the  fibres  forming  the  individual  posterior 
roots,  and  also  to  understand  which  muscles  receive  their 
nerve  fibres  from  the  cells  ui  any  given  spinal  segments. 

The  distribution  of  the  peripheral  nerves,  both  motor  and 
sensory,  is  described  in  every  text-book  of  anatomy  and  will 
not  be  discussed  here. 

The  sensory  segmental  distribution  can  be  understood  by 
reference  to  Figs.  71  and  72,  which  need  no  description. 
It  is,  however,  important  to  remember  that  the  diagrams 
indicate  the  principal  sensory  supply  only,  since,  as  stated 
above,  there  is  considerable  overlapping  from  the  segments 
next  above  and  below. 

The  motor  segmental  distribution  for  the  principal  muscles 
is  as  follows  : — 

Muscles  of  the  Upper  Extremity. 

Supraspinatus  and  teres  minor       .         .  C.  5 

Deltoid,     infraspinatus,     subscapularis, 

biceps,       brachialis     anticus,      and 

supinator  longus         ....  C.  5 — 6 

31—2 


2.O.C. 


Flu.  71. — Diagram  to  show  tlie  segmental  distribution 
of  the  Sensory  Nerves. 


Fio.  72. — Diagram  to  show  tho  sigiucutal  distribution 
of  th«  JSeuaory  ^tlerveu. 


486 


MEDICAL  DIAGNOSIS 


Muscles  of  the  Upper  Extremity — continued 

Teres  major,  supinator  brevis,  extensor 
carpi  radialis  longior  and  brevior 

Coraco-brachialis,  pronator  radii  teres, 
flexor  carpi  radialis,  flexor  longus 
pollicis,  abductor  poUicis,  extensor 
brevis  pollicis,  flexor  brevis  pollicis, 
opponens  pollicis         .... 

Triceps,  extensor  longus  pollicis, 
extensor  communis  digitorum,  ex- 
tensor indicis,  extensor  carpi  ulnaris, 
extensor  minimi  digiti 

Anconaeus      ...... 

Flexor  sublimis  digitorum,  flexor  pro- 
fundus digitorum,  flexor  carpi  ulnaris, 
pronator  quadratus,  palmaris  longus 
flexor  minimi  digiti,  opponens  minimi 
digiti  ..... 

Adductor  pollicis,  palmaris  brevis 
abductor  minimi  digiti,  lumbricales 
interossei  ..... 


C.  5—7 


C.  6—7 


C.  6—8 

C.  7—8 


C.  7— D.  1 


0.  8— D.  1 


Muscles  of  the  Lower  Extremity. 

Psoas    .         .         .         .         .         .         .  D.  12— L.  4 

Sartorius,  pectineus,  adductor  longus  L.  2 — L.  3 

Gracilis,  adductor  brevis,  quadriceps  .  L.  2 — L.  4 
Adductor  magnus,  adductor  minimus, 

obturator  externus     .         .         .          .  L.  3— L.  4 

Tensor  fascise  femoris,  tibialis  anticus  L.  4 — L.  5 
Glutseus     medius,     glutseus     minimus, 

quadratus  femoris,  gemellus  inferior, 

semi-tendinosus,   semi-membranosus, 

extensor    longus    hallucis,    extensor 

longus  digitorum,  popliteus,  plantaris  L.  4 — S.  1 
Biceps,   soleus,   gastrocnemius,  glutseus 

maximus,  gemellus  superior.  .  .  L.  4 — S.  2 
Peroneus"    longus,      peroneus     brevis, 

adductor  obliquus  hallucis          .         .  L.  5 — S.  1 


DISEASES   OF   THE   NERVOUS   SYSTEM        487 

Muscles  of  the  Lower  Extremity — continued. 

Obturator    internus,    tibialis    posticus, 

flexor      longus      digitorum,      flexor 

longus       hallucis,       flexor       brevis 

hallucis,  lumbricales  ....  L.  5 — S.  2 

Pyriformis.  abductor  hallucis.  abductor 

minimi   digiti,  flexor    brevis  minimi 

digiti,      opponens      minimi      digiti. 

iiitei'ossei    ......  S.   1 — S.   2 


The  Trinik  Muscles. 

Short  deep  cervical  muscles  . 

Splenius,  scaleni    . 

Trapezius       .... 

Latissimus  dorsi     . 

Levator  anguli  scapulae 

Rhomboidaei 

Longus  capitis 

Longus  colli  . 

Pectoralis  major    . 

Subclavius 

Pectoralis  minor    . 

Serratus  magnus   . 

Diaphragm    . 

Rectus       abdominis       and       external 

oblique       .... 
Transversalis  abdominis 
Internal  oblique    . 
Quadratus  lumborum 
Levator  ani,  sphincter  ani,  etc 


C.  1- 
C.  3- 
C.  2- 
C.  6- 
C.  ^- 
C.  4- 
C.  1- 
0.  5- 


C. 
C. 
C. 
C. 


C.  3- 


-C.  2 
-C.  8 
-C.  4 
-C.  8 
-C.  5 
-C.  5 
-C.  4 
-C.  8 
-D.  1 
-C.  6 
-D.  1 
-C.  7 
-C.  5 


D.  5— D  12 
D.  7— L.  1 

D.  8— L.  1 
D.  10— L.  4 

S.  3— S.  5 


CHAPTER    TI 
THE  CRANIAL  NERVES 

I.  The  Olfactory  Nerves.  The  olfactory  nerves  enter  the 
skull  through  the  cribriform  plate  in  the  ethmoid  and  join 
the  olfactory  bulb  from  which  the  olfactory  tracts  run  to  the 
brain.  Each  tract  divides  into  two  parts,  one  of  which 
crosses  to  the  other  side  by  the  anterior  commissure  and  the 
other  runs  towards  the  temporal  lobe  of  the  same  side. 
The  cortical  smell  centre  is  probably  in  the  uncinate  gyrus. 

Anosmia.  Loss  of  sense  of  smell  is  not  usually  a  sign  of 
organic  nerve  lesions  ;  more  often  it  depends  on  some  local 
condition  in  the  nose. 

Anosmia  may  be  found  in  fractures  of  the  anterior  fossa 
of  the  skull  if  the  olfactory  tracts  are  damaged  or  for  a 
similar  reason  in  tumour  or  inflammation  of  the  lower 
surface  of  the  frontal  lobe  ;  it  may  also  be  a  manifestation 
of  hysteria. 

Parosmia  (perverse  sensations  of  smell)  may  occur  in 
insanity,  as  an  aura  in  epilepsy,  or  in  tumours  of  the  temporal 
lobe  Avhich  involve  the  cortical  centre. 

II.  The  Optic  Nerve.  The  optic  nerves  run  backwards 
from  the  retinse,  and  the  fibres  from  the  nasal  half  of  each 
retina  decussate  at  the  optic  chiasma,  while  the  fibres  from 
the  temporal  halves  of  the  retinae  bend  outwards  again  into 
the  optic  tract  of  the  same  side.  The  result  is  that  each 
optic  tract  corresponds  to  the  temporal  half  of  the  homo- 
lateral retina  and  to  the  nasal  half  of  the  contra-lateral 
retina.  Fibres  from  the  actual  macula  appear  to  separate, 
part  decussating  and  part  remaining  homolateral.  The 
optic  tracts  terminate  in  three  cell  stations.  The  greatest 
number  of  fibres  go  to  the  external  geniculate  body,  a  smaller 
number  go  to  the  superior  corpus  quadrigeminum  and  to  the 
pulvinar  of  the  optic  thalamus.  From  these  three  cell 
stations  the  optic  radiations  run  backwards  through   the 


Corp  Cenic 
Tnt 


niJVerve  JVuclei/i 


Occipifal  Lode 


Fic.  7."^.     Diagram  to  show  the  ananf^ement  of  the  Optic 
NiTves,  'J'racts,  and  Radiations. 


THE   CRANIAL   NERVES  489 

hindmost  part  of  the  internal  capsule  to  the  cortical  visual 
centres  in  the  occipital  lobes  {vide  Fig.  73). 

The  half-vision  centre  is  situated  on  the  mesial  aspect  of 
the  occipital  lobe  round  the  calcarine  fissure. 

It  is  noteworthy  that  the  calcarme  artery  has  probably 
the  poorest  anastomosis  of  any  cerebral  artery,  so  that 
hemianopia  due  to  thrombosis  of  this  vessel  hardly  ever 
shows  any  improvement  in  vision. 

The  pupillary  light  reflex  is  accomplished  by  the  passage 
of  a  stimulus  along  the  optic  nerve  and  tract  to  the  superior 
corpus  quadrigeminum,  thence  to  the  nucleus  of  the  third 
nerve  by  an  association  tract,  and  so  via  the  ciliary  ganglion 
to  the  sphincter  pupillee. 

Dilatation  of  the  pupil  is  governed  by  the  inferior  cervical 
sympathetic  ganglion  via  the  long  ciliary  branches  of  the 
ophthalmic  branch  of  the  fifth  cranial  nerve  (vide  also  p.  495). 

From  the  preceding  remarks  it  is  clear  that  a  lesion  of 
one  optic  nerve  causes  blindness  of  the  corresponding  eye  ; 
that  a  lesion  at  the  centre  of  the  optic  chiasma  causes 
bitemporal  hemianopia  (loss  of  vision  in  the  nasal  half  of 
each  retina)  ;  that  a  symmetrical  lesion  of  the  outside 
fibres  of  the  optic  chiasma  would  be  necessary  to  produce 
binasal  hemianopia  ;  and  that  a  lesion  anywhere  behind 
the  optic  chiasma,  between  it  and  the  cortical  visual  centre, 
causes  homonymous  hemianopia  (loss  of  vision  for  the  nasal 
half  of  the  retina  of  the  opposite  eye  and  for  the  temporal 
half  of  the  retina  of  the  eye  on  the  same  side  as  the  lesion). 

If,  however,  the  lesion  causing  homonymous  hemianopia 
is  at  or  in  front  of  the  superior  corpus  quadrigeminujn  the 
pupil  will  not  contract  when  a  pencil  of  light  is  projected  on 
to  the  hlind  half  of  the  retina,  whereas  if  the  lesion  is  in  the 
occipital  pole  or  optic  radiations  the  pupil  will  contrac^t 
undei'  the  above  cinMimstances  because  the  reHex  piitli  is 
intact  (Wernicke's  hejniopi(;  i>upillarv  reaction). 

In  homonymous  hejniano])ia  tlu^  blind  ai-ea  of  the  letina 
does  not.  as  a  rule,  include  the  macula.  This  is  explained  by 
the  fact  that  the  macula  has  a  double  cortical  representation 
by  reason  of  the  partial  decussation  of  its  fibres  at  the 
chiasma. 

Optic  Neuritis.     This  may  be  produced  by  anything  which 


490  MEDICAL   DIAGNOSIS 

causes  increase  in  intracranial  pressure  such  as  tumour  or 
abscess,  or,  more  rarely,  meningitis  ;  it  is  also  seen  in 
morbid  blood  states,  such  as  chronic  nephritis,  grave  anaemia, 
lead  poisoning,  etc. 

It  is  remarkable  what  good  vision  can  be  preserved  with 
even  high  degrees  of  swelling  ;  blurring  of  vision  and  slight 
contraction  of  the  visual  fields  are  all  that  can  be  detected  in 
many  cases  until  optic  atrophy  supervenes,  when,  of  course, 
permanent  blindness  develops.  Hence  the  importance  of  a 
routine  examination  with  the  ophthalmoscope. 

Opiic,  Atrophy.  This  may  develop  in  three  ways  and  can 
readily  be  diagnosed  by  the  ophthalmoscope  : — 

(i.)  Primary  optic  atrophy  as  seen  in  tabes,  general 
paralysis  of  the  insane,  disseminated  sclerosis,  ajnaurotic 
family  idiocy,  etc. 

(ii.)  Secondary  optic  atrophy,  which  follows  some  injury 
to  the  optic  nerve,  as  in  fractured  base  of  the  skull,  or  some 
other  lesion  which  is  not  accompanied  by  optic  neuritis. 

(iii.)  Consecutive  optic  atrophy,  which  follows  unrelieved 
optic  neuritis. 

Primary  optic  atrophy  sliows  a  (;lear-cut  greyish-Avhitc 
disc  witli  normal  blood-vessels. 

Consecutive  optic  atrophy  shows  a  white  disc  with  blurred 
edges  and  small  arteries. 

III.  The  Oculo-Motor  Nerves  (Third,  Fourth  and  Sixth). 
The  third  nerve  supplies  the  levator  palpebrse  superioris, 
the  contractor  fibres  to  the  iris,  and  all  the  external  muscles 
of  the  eye  except  the  superior  oblique  and  the  external 
rectus,  which  are  supplied  by  the  fourth  and  sixth  nerves 
respectively. 

The  nuclei  for  the  third  nerve  are  situated  beneath  the 
floor  of  the  fourth  ventricle  and  the  front  part  of  the  Sylvian 
aqueduct  and  extend  in  a  vertico-caudal  direction  for  a 
considerable  distance. 

Three  main  groups  can  be  recognised,  the  foremost  of 
which  sends  fibres  to  the  ciliary  ganglion  and  is  the  centre 
for  the  sphincter  papillae  ;  the  next,  or  mesial  nucleus,  is 
the  centre  for  accommodation ;  while  the  hindermost 
nuclear  mass  is  itself  composed  of  five  small  nuclei,  which, 
though  closely  adjacent  to  each  other,  are  functionally  quite 


^p 


sphincter 
Ptipi  /lae 

Lev.  Palp- 

Rectus  Superior 

\QbIia  uus  In  ferCor 
Rectus  Internum 

i  Rectus  Inferior 
\Obliauus  Superior 

Rectus  Jlx  iernus 


Clccommodation 
and  Con  ver^ence 


^^^      ^  IF  Nerve 

-0       O  "am 


M.\, 


/erve 


Vu:    74.      Diai^'ranimiitic  ivpn-scntatidii  nt  the  Orulo-mutor  Xmlcus. 


THE   CRANIAL   NERVES  491 

distinct.     From  before  backwards  these  five  small  nuclei 
are  as  follows  {vide  Fig.  74) : — 

(i.)  The  centre  for  levator  palpebrse  ] 

superioris  [    i.e.,  looking 

(ii.)  The  centre  for  superior  rectus  '       upwards, 

(iii.)  The  centre  for  inferior  oblique  j 
(iv.)  The  centre  for  internal  rectus 

(v.)  The  centre  for  inferior  rectus  .  .(«.e.,  looking 

doAvnwards) . 

Immediately  behind  this  third  nerve  nucleus  lies  that  for 
the  fourth  nerve,  the  function  of  which  is  to  move  the  cornea 
do\vnwards  and  outwards  by  means  of  the  superior  oblique 
muscle.  It  is  noteworthy  that  the  fibres  of  the  fourth  nerve 
decussate  completely  after  leaving  their  nuclei.  It  is  probable 
that  the  fibres  from  the  centres  for  internal  rectus,  inferior 
oblique,  and  inferior  rectus  undergo  a  partial  decussation 
after  leaving  their  nuclei,  as  represented  in  the  diagram. 

A  considerable  distance  behind  the  fourth  nerve  nucleus — 
that  is  to  say,  lower  down  the  pons,  but  in  the  same  plane — 
is  the  sixth  nerve  nucleus,  which  supplies  the  external 
rectus  muscle  for  the  same  side,  but  also  sends  a  fibre  to  the 
nucleus  for  the  internal  rectus  of  the  opposite  side  in  order 
to  produce  synergic  lateral  deviation  of  the  eyes. 

Oculo-motor  Paralysis  may  occur  as  a  congenital  affection 
or  it  may  be  acquired  in  the  following  conditions  : — 

(i.)  Systemic  nervous  diseases,  such  as  tabes  dorsalis  or 
disseminated  sclerosis. 

(ii.)  Polio -encephalitis  affecting  the  brain  stem, 
(iii.)  New  growth  or  vascular  lesions  in  the  brain  stem, 
(iv.)  Basal  meningitis  due  to  syphilis  or  tuberculosis  or 
following  fractures  of  the  sphenoidal  fissure  or  orbit, 
(v.)  Toxic  neuritis,  as  in  diphtheria, 
(vi.)  Cortical  lesions  may  disturb  conjugate  deviation, 
(vii.)  Hysteria  and  migraine. 

(viii.)  Any  condition  which  produces  a  great  increase  in 
intracranial  tension  may  produce  a  partial  ophthalmo- 
plegia. The  most  usual  phenonunion  is  an  external  re(^tus 
palsy  (single  or  double).  This  may  be  explained  in  part 
by  the  long  intracranial  course  of  the  sixth  nerve  and  its 


492  MEDICAL   DIAGNOSIS 

extreme  antero-posterior  direction,  which  renders  it  par- 
ticularly liable  to  be  pulled  upon  when  the  brain  sinks 
backwards  and  the  mediilla  is  depressed  into  the  foramen 
magnum  in  the  effort  to  make  room  for  tiie  increased 
amount  of  cerebro -spinal  fluid. 
Hence  it  is  obvious  that  an  external  rectus  palsy  by  itself 

is  not  often  of  great  value  as  a  localising  sign  of  intracranial 

disease. 

Cotnplete  Ophthalmoplegia  includes  the  third,  fourth,  and 

sixth  nerves. 

The  eye  is  immobile,  the  pupil  is  dilated  (sympathetic) 

and  central,  and  the  upper  lid  is  dropped. 

Ophthalmoplegia    Interna     includes    only    the     internal 

ocular  muscles.     If  the  thkd  nerve  only  is  affected  the  eye 

is  turned  downwards  and  outwards  by  the  action  of  the 

superior  oblique  and  external  rectus  muscles. 

A  Partial  Op>hthalmoplegia  gives  rise  to  the  following  signs 

and  symptoms  : — 

(i.)  Loss  of  movement  of  the  eye  in  the  direction  of 
action  of  the  paratysed  muscle. 

(ii.)  Diplopia  for  such  positions  of  the  eyes  as  would 
involve  the  action  of  the  paralysed  muscle. 

The  diplopia  is  crossed  in  cases  of  divergent  strabismus, 
that  is  to  say,  the  false  image  is  on  the  side  of  the  sound 
eye  ;    the  converse  obtains  in  convergent  strabismus. 

(iii.)  Secondary  Deviation.  If  the  paralysed  eye  is 
covered  and  an  object  fixed  with  the  other  eye,  the  para- 
lysed eye  can  be  observed  to  "swing  "  as  the  other  eye 
fixes  ;    this  is  "  primary  "  deviation. 

If  the  converse  experiment  is  now  performed  by  covering 
the  sound  eye  and  fixing  with  the  paralysed  eye,  the  sound 
eye  also  swings  when  the  paralysed  eye  fixes  ;  this  is 
"  secondary  "  deviation,  and  "  secondary  "'  deviation  is 
greater  than  "  primary  "  deviation  except  in  the  con- 
genital affection  known  as  Concomitant  Strabismus,  when 
the  two  deviations  are  equal  in  amplitude  of  swmg. 

(iv.)  Strabismus,  or  squint,  is  simply  faulty  convergence 
of  the  visual  axes  and  may  be  so  slight  as  to  escape 
observation. 

(v.)  Erroneous  Projection  of  the  Visual  Field.     If  the 


THE   CRANIAL   NERVES  40:5 

patient  is  asked  to  touch  an  object  wliicli  is  held  in  such 

a  position  as  to  make  hun  try  to  use  his  paralysed  muscle 

when  he  looks  at  it,  he  will  always  make  a  faulty  estimate 

of  the  position  of  the  object  and  place  his  finger  beyond 

the  object  in  the  direction  of  action  of  the  paralysed  action. 

It  is  not  always  obvious  which  muscle  is  paralysed  ;   this 

can,    however,    usually    be    ascertained    in    the    following 

manner.     First  place   a   different   coloured  glass   in   front 

of  each  eye  so  that  it  is  possible  to  say  at  once  which  image 

belongs  to  which  eye  ;    next  note  whether  the  diplopia  is 

crossed  or  homonymous — for  example,  if  there  is  a  red  glass 

over  the  right  eye  and  a  blue  glass  over  the  left,  the  diplopia 

is  homonymous  if  the  red  image  is  on  the  patient's  right 

and  the  blue  image  on  his  left. 

We  can  now  apply  the  rule  that  "  that  eye  is  affected  in 
the  direction  of  the  image  of  which  the  diplopia  increases." 
For  example,  suppose  the  distance  between  the  images 
increases  when  the  patient  looks  to  his  right  and  the  diplopia 
is  homonymous,  then  the  right  eye  is  the  affected  one  ;  if 
the  diplopia  is  crossed,  then  the  right  image  corresponds 
to  the  left  eye  and  therefore  the  left  eye  is  affected. 

Having  in  this  manner  ascertained  in  which  eye  the 
paralysed  muscle  is  situated,  we  can  apply  the  second  of 
Landolt's  laws,  which  teUs  us  that  the  false  image  (that  is  to 
say,  the  image  corresponding  to  the  affected  eye)  bears 
that  position  in  relation  to  the  true  image  which  the  affected 
muscle  would  give  to  the  eye.  For  example,  if  the  false 
image  is  above  and  to  the  left  of  the  true  image  and  also  with 
its  upper  end  tilted  to  the  left,  and  if  it  is  known  that  the 
right  eye  is  affected,  then  the  right  superior  rectus  is  the 
affected  muscle,  for  this  muscle  moves  the  eye  upwards 
and  also  rotates  it  somewhat  obliquely  to  the  left. 

As  a  general  rule  it  may  be  stated  that  the  cortical 
innervation  of  the  ocular  muscles  is  so  largely  bilateral 
that  heiniplegic  supranuclear  lesions  do  not  cause  ophthal- 
moplegia. Cortical  lesions  sometimes  cause  a  contra-lateral 
kn'ator  ]>aIpebr8B  paralysis,  and  may  also  cause  conjugate 
deviation  of  the  eye  to  the  side  of  the  lesion  in  a  destructive 
lesion,  or  to  the  opposite  side  in  an  irritative  lesion,  through 
the   <»|)])<)site  sixtli    muileuB.     In   like   Jiuinner  an    irritative 


494  MEDICAL   DIAGNOSIS 

lesion  of  the  pons  may  cause  conjugate  deviation  to  the  same 
side,  or  a  destructive  lesion  to  the  opposite  side.  In  these 
cases  there  may  be  involvement  of  the  facial  nerve  as  well, 
because  the  sixth  nucleus  is  surrounded  by  the  intramedullary 
root  fibres  of  the  facial  nerve. 

Nuclear  lesions  of  the  oculo -motor  system  are  rare,  but 
may  sometimes  be  seen  in  polio -encephalitis  ;  though  owing 
to  the  extensive  nuclear  area  the  entire  nucleus  is  not  often 
aifected.  In  contrast  to  an  infra-nuclear  lesion,  the  orbi- 
cularis palpebrarum  is  paralysed  m  nuclear  lesions,  since 
this  muscle  is  supplied  from  the  thud  nucleus  via,  the 
seventh  nerve. 

A  nuclear  lesion  of  the  sixth  nerve  in  addition  to  the  external 
rectus  nmscle  of  the  same  side  affects  the  opposite  mternal 
rectus  as  far  as  conjugate  deviation  is  concerned,  but  does 
not  interfere  with  this  muscle  when  used  for  accommodation. 

In  addition,  sixth-nerve  nuclear  })alsy  is  often  accompanied 
by  facial  paralysis  of  infra-nuclear  type  owing  to  the  proximity 
of  the  facial  nerve  during  its  mtra-pontine  course. 

Gross  lesions  of  the  brain  stem  are,  of  course,  liable  to 
involve  the  oculo-motor  nerves  and  their  nuclei,  but  the 
hemiplegic  or  diplegic  signs  will  be  present  also.  In  this 
maimer  a  lesion  of  the  crus  may  cause  paralysis  of  the 
opposite  face  and  limbs  and  of  the  oculo-motor  nerve  on 
the  same  side. 

In  most  cases  of  oculo-motor  paralysis  associated  Avith 
gross  brain  stem  lesions  the  oculo-motor  paralysis  is  of  the 
"  lower  "  or  degenerative  type,  and  is  due  to  involvement 
of  the  nuclei  or  the  nerves  below  the  nuclei. 

Unilateral  ophthalmoplegias,  whether  partial  or  complete, 
are,  in  the  majority  of  cases,  due  to  lesions  at  the  base  of 
the  brain,  e.g.,  tuberculoma  or  gummatous  meningitis. 

It  is  worthy  of  note  that  the  oculo-motor  nerves  may  be 
the  subject  of  a  paralysis  which  is  etiologically  identical 
with  Bell's  palsy  as  seen  affecting  the  seventh  nerve. 

Nystagmus.  "By  nystagmus  is  meant  rhythmical  oscilla- 
tion of  the  eyeball ;  it  may  be  rotary,  lateral  or  vertical, 
and  may  be  constantly  present  or  only  to  be  seen  when  certain 
muscles  are  put  on  the  stretch. 

Nystagmus  is  commonly  due  to  lack  of  proper  co-ordinating 


THE   CRANIAL   NERVES  495 

control,  and  is  therefore  found  in  lesions  of  the  cerebellum 
or  of  the  mid-brain  and  tegmentum  pontis  if  the  dorsal 
longitudinal  bundle  is  involved.  In  these  cases  the  nystag- 
mus is  most  marked,  or  perhaps  only  found  on  looking 
towards  the  side  of  the  lesion. 

Douching  the  ears  with  cold  water  is  apt  to  cause 
nystagmus  to  the  opposite  side,  while  if  hot  water  is  used 
the  nystagmus  is  to  the  same  side.  These  mipulses  are  con- 
veyed from  the  labyrinth  via  the  vestibular  system  to  the 
dorsal  longitudinal  bundle.  Inflammatory  affections  of  the 
internal  ear  can  produce  nystagmus  in  a  like  manner. 

In  disseminated  sclerosis  and  Friedreich's  disease  the  nys- 
tagmus may  be  regarded  as  akui  to  the  intention  tremor, 
which  is  so  marked  a  feature  of  these  diseases. 

Nystagmus  may  also  be  met  Avith  under  the  following 

cucumstances  : —  ^ 

(i.)  Occupations   imposing   constant   lateral    strain   on 

the  eye,  e.g.,  coal  miner. 

(ii.)  In  toxic  neuritis,  e.g.,  diphtheria. 

(iii.)  In  congenital  ocular  defect,  such  as  optic  atrophy, 

albinism,   congenital   cataract,   etc.,   in   which   the   child 

has  never  seen  well  enough  to  learn  to  "  fix  "  objects, 
(iv.)  In  central  defects  of  congenital  nature  and  obscure 

patholog\',  often    familial,  and    sometimes    accompanied 

by  other  tremors,  such  as  spasmus  nutans  or  head-nodtling. 

The  PupiUary  Light  Reflex.  The  ])ath  for  this  icflex 
is  probably  as  follows  :  -  From  the  rethia  through  the  optic 
nerve  and  tract  to  the  superior  corpus  quadrigeminum, 
thence  by  association  fibres  to  the  anterior  portion  of  the 
third  nerve  nucleus  and  so  to  the  ciliary  ganglion,  and  thence 
to  the  sphincter  pupillse  muscle.  It  is  probable  that  the 
centre  of  control  for  this  reflex  lies  in  the  ciliary  ganglion. 

The  dilating  mechanism  is  under  the  control  of  the  cervical 
sympathetic  system  ;  the  path  for  reflex  dilatation  runs 
from  the  retina  to  the  brain  stem,  then  down  the  cord  to 
the  first  and  second  dorsal  segments,  where  it  leaves  the 
cord  ill  the  white  rami  communicantes  and  runs  to  the 
inferior  cervical  ganglion,  and  subsequently  to  the  long 
ciliary  ])ran(;hes  of  the  ophthalmic  branch  of  the  fifth 
cranial  nerve  and  so  to  the  iris. 


496  MEDICAL   DIAGNOSIS 

iV.  The  Fifth  Cranial  Nerve  (Trigeminal).  The  gas- 
serian  ganglion  is  the  sensory  ('ell  imcleus  for  the  fifth 
nerve  ;  the  motor  nucleus  is  formed  in  part  by  a  mass  of 
cells  which  is  situated  laterally  in  the  tegmentum  pontis 
and  in  part  by  a  strip  of  cells  running  down  to  the  cervical 
cord  (spinal  root). 

The  motor  root  supplies  the  muscles  of  mastication  ; 
the  sensory  branches  supply  the  skin  of  the  face  (except  the 
auricle  and  the  greater  part  of  the  lower  jaw),  the  con- 
junctiva and  the  mucous  membrane  of  the  tongue  as  far  as 
the  circumA^allate  papUlse  and  of  the  mouth  and  cheeks  as 
far  as  the  anterior  pillars  of  the  fauces,  and  lastly  all  the 
teeth. 

The  chorda  tympani  conveys  taste  fibres  from  the  anterior 
two-thirds  of  the  tongue  and  leaves  the  tongue  in  the  lingual 
branch  of  the  fifth,  but  soon  leaves  this  nerve  to  join  the  facial 
nerve. 

Some  wiiters  hold  that  these  taste  fibres  enter  the  brain 
in  the  fifth  nerve,  and  assume  that  they  leave  the  facial 
nerve  at  its  geniculate  ganglion  and  run  in  the  great  super- 
ficial petrosal  nerve  to  Meckel's  ganglion  and  so  to  the  second 
division  of  the  fifth  nerve. 

In  like  manner  it  is  possible  to  construct  a  path  to  the 
fifth  nerve  for  the  taste  fibres  of  the  posterior  part  of  the 
tongue  which  leave  in  the  glosso-pharyngeal  nerve  ;  they 
may  be  said  to  run  in  the  tympanic  branch  of  the  glosso- 
pharyngeal to  the  small  superficial  petrosal  nerve,  and  so  to 
the  otic  ganglion,  and  finally  to  the  third  division  of  the 
fifth  nerve. 

Since,  however,  excision  of  the  gasserian  ganglion,  and 
even  section  of  the  entire  fifth  nerve,  is  only  very  rarely 
followed  by  loss  of  taste  for  the  corresponding  half  of  the 
tongue,  it  is  probable  that  the  taste  fibres  really  enter  the 
brain  through  the  glosso-pharyngeal  nerve  and  the  sensory 
root  of  the  facial  respectively. 

The  course  of  the  taste  fibres  in  the  brain  is  not  knoAvn  ; 
it  is  probable  that  eventually  they  reach  the  anterior  pole 
of  the  temporo-sphenoidal  lobe.  They  do  not  pass  through 
the  internal  capsule. 

Paralysis  of  the  fifth  nerve  may  be  caused  by  lesions  in 


THE   CRANIAL  NERVES  497 

the  pons  affecting  the  nuclei,  by  lesions  at  the  base  of  the 
brain  affecting  the  nerve  roots,  or  by  lesions  of  the  peripheral 
course  of  the  nerves. 

If  the  motor  part  of  the  nerve  is  affected  the  jaw  swings 
to  the  paralysed  side  when  the  mouth  is  opened. 

If  the  sensory  part  of  the  nerve  is  affected  there  may  be 
complete  anaesthesia  of  its  area  of  cutaneous  distribution. 
When  this  happens  trophic  ulcers  of  the  cornea  are  cojnmonly 
found . 

Trigeminal  Neuralgia  consists  of  violent  pain,  sometimes 
persistent,  but  more  often  paroxysmal  and  oft  repeated, 
referred  to  the  area  supplied  by  one  or  more  sensory  branches 
of  the  fifth  nerve.  The  affected  part  may  be  swollen,  glazed, 
and  tender.  The  paroxysms  appear  to  be  started  by  trivial 
reflex  causes,  such  as  smiling,  eating,  etc. 

The  condition  is  often  characterised  by  tender  spots  where 
the  branches  of  the  nerve  become  subcutaneous,  and  the 
pain  appears  to  start  at  these  spots  and  thence  to  radiate 
peripheralh^  along  the  branch. 

Certain  of  these  cases  are  due  to  reflex  causes,  such  as 
carious  teeth,  refractive  errors  or  naso-pharyngeal  disease, 
and  these  must  always  be  carefully  excluded,  but  in  many  no 
cause  can  be  found,  though  possibly  there  may  be  some 
interstitial  inflammation  in  the  gasserian  ganglion. 

v.  The  Seventh  Cranial  Nerve  (the  Facial).  The  motor 
nucleus  for  this  nerve  is  situated  beneath  the  floor  of  the 
fourth  ventricle.  The  sensory  part  of  the  nerve  arises  in 
the  geniculate  ganglion  and  luns  into  the  brain  as  the  "  pars 
intermedia  "  of  Wrisberg. 

The  motor  supply  is  to  all  the  muscles  of  facial  expression 
excepting  levator  palpebrae  superior  is  and  to  the  occipito- 
frontalis  muscle,  the  muscles  of  the  pinna,  and  also  to 
the  stapedius  muscle  ;  the  sensory  fibres  probably  forni 
part  of  the  supply  to  the  skin  of  the  external  auditory 
meatus  and  the  front  of  the  external  ear.  The  pars  inter- 
media anastomoses  with  the  trigeminal  nerve,  and  from  this 
the  corda  tympani  is  formed,  which  contains  salivary 
and  taste  fibres. 

Although  the  orbiciilaris  oris  and  the  (irhiciilaris  palpe- 
brarum are  supplied  by  fibres  of  the  fa<?ial  nerve,  it  is  probable 

M.D.  32 


498  MEDICAL  DIAGNOSIS 

that  these  muscles  are  not  supplied  from  the  seventh 
nucleus,  but  from  the  hypoglossal  and  third  nerve  nuclei 
respectively,  the  communications  being  with  the  facial 
nerve  after  it  leaves  its  nucleus  or  with  the  upper  part  of 
the  facial  nucleus  itself  via  the  posterior  longitudinal 
bundle. 

The  facial  nerve  has  a  very  long  intra -pontine  course,  and 
it  winds  round  the  sixth  nucleus  before  emerging  on  the 
ventro -lateral  aspect  of  the  pons  between  the  olivary  and 
restiform  bodies  close  to  the  cerebello-pontine  angle. 

The  facial  nerve  now  enters  the  internal  auditory  meatus 
with  the  eighth  nerve,  passes  through  the  aqueductus 
Fallopii,  across  the  roof  of  the  middle  ear,  and  emerges  through 
the  stylo -mastoid  foramen.  The  upper  part  of  the  facial 
nucleus  receives  a  bilateral  cortical  supply  ;  this  comprises 
the  frontalis  and  possibly  also,  as  indicated  above,  the  orbi- 
cularis palpebrarum.  The  upper  motor  neuron  to  the  facial 
nucleus  decussates  about  the  middle  of  the  pons. 

Lesions  causing  a  facial  paralysis  may  be  situated  any- 
where from  the  cerebral  cortex  to  the  peripheral  distribution 
of  the  nerve.  It  is  usually  possible  to  localise  the  lesion 
with  considerable  accuracy. 

(i.)  Infra -nuclear  Lesions.  The  most  common  cause  is 
exposure  to  chill  or  tlraught,  which  sets  up  a  parenchjauatous 
neuritis  at  or  about  the  lower  end  of  the  aqueduct  ;  other 
causes  may  be  middle-ear  disease,  operations  on  the  mastoid, 
bii'th  injuries  from  forceps,  syphilis,  basal  meningitis,  and 
tumours  of  the  cerebello-pontine  angle.  If  facial  palsy  is 
produced  spontaneovsly  from  mastoid  disease  the  disease  is 
usually  tuberculosis. 

Infra-nuclear  facial  paralysis  is  generally  unilateral, 
unless  due  to  basal  meningitis.     The  signs  are  characteristic  : 

AH  the  muscles  of  that  side  of  the  face  are  paralysed,  and 
it  consequently  becomes  smoothed  and  free  from  wrinkles  ; 
the  patient  is  unable  to  shut  his  eye,  frown,  whistle,  or  smile  ; 
tears  overflow  on  to  the  cheek,  and  food  collects  in  the  cheek 
and  tends  to  run  out  of  the  corner  of  the  mouth. 

The  following  additional  points  should  be  remembered  : — 
(a)  Lesions  at  the  base  of  the  brain  (syphilitic  meningitis 

or  tumour)  usually  involve  other  cranial  nerves  as  well, 


THE   CRANIAL   NERVES  499 

especially  6,  9,  10,  11,  and  12,  and  are  often  associated 
with  general  cerebral  symptoms,  such  as  headache  and 
vomiting. 

(6)  Lesions  in  the  aqueductus  Fallopii  proximal  to 
the  junction  of  the  chorda  tympani  and  below  the  geni- 
culate ganglion  give  loss  of  taste  for  the  anterior  two- 
thirds  of  the  homolateral  half -tongue  and  also  diminished 
salivary  secretion  on  that  side.  Further,  if  the  lesion  is 
proximal  to  the  nerve  to  the  stapedius,  that  muscle  is 
paralysed,  with  the  result  that  there  is  hyperacusis  on  that 
side  from  the  ability  to  detect  notes  of  fewer  vibrations 
than  is  normally  the  case. 

(c)  Lesions  between  the  internal  auditory  meatus  and 
the  geniculate  ganglion  cause  diminished  salivation  but 
no  loss  of  taste  ;  there  is,  however,  often  nerv^e  deafness 
from  implication  of  the  eighth  nerve,  and  this,  fvhen 
present,  masks  the  hyperacusis  which  can  otherwise  be 
recognised. 

(ii.)  Nuclear  Lesions.  Nuclear  lesions  of  the.  facial  nerve 
alone  are  rare,  but  may  be  seen  occasionally  in  poliomyelitis 
acuta. 

Chronic  lesions  in  the  course  of  bulbar  paralysis  are  not 
uncommon  and  are  associated  with  paralysis  of  other  bulbar 
nerves,  often  as  a  late  stage  of  ])rogressive  muscular  atrophy 
{vide  p.  554). 

In  a  pure  nuclear  lesion  the  upper  part  of  the  luicleus 
may  escape  and  the  orbicularis  iDalpebrarum  may  be  un- 
affected owing  to  its  probable  supply  from  the  third  nucleus. 
Lesions  in  the  pons  may,  of  course,  affect  the  nuclei, 
and  also  the  nerve  after  it  leaves  its  nucleus  but  before  it 
leaves  the  pons.  Such  cases  often  leave  the  upper  face  un- 
affected, and  are  usually  accompanied  by  a  sixth  nerve  palsy 
on  the  same  side,  and  often  by  a  paralj'sis  of  the  limbs  on 
the  opposite  side  from  pyramidal  involvement,  or  a  crossed 
hemi-anoesthesia  from  interference  Avith  the  sensory  fibres 
in  the  fillet. 

(iii.)  Supra -nuclear  Lesions.  In  these  the  paralysis  is 
crossed  and  the  lower  face  only  is  obviously  paralysed, 
though  there  is  usually  demonstrable  weakness  of  the  upper 
face  muscles  as  well.     The  reason  why  the  upper  face  escapes 

32—2 


500  MEDICAL  DIAGNOSIS 

almost  completely  is  that  the  upper  muscles  are  always 
used  together  with  thek  fellows  of  the  opposite  side  (even 
winking  requires  assiduous  practice  and  is  not  a  natural 
act)  and  therefore  receive  a  bilateral  cortical  suppW.  Con- 
sequently so  long  as  the  nuclei  and  the  peripheral  nerve - 
tracts  are  intact  the  muscles  will  work  provided  that  any 
impulse  can  reach  them  from  either  cortex. 

Emotional  movements,  such  as  laughing  or  smiling, 
remam  relatively  unimpaired  in  supra -nuclear  lesions 
provided  that  the  optic  thalamus  is  not  involved. 

By  reason  of  the  close  proximity  of  other  pyramidal 
fibres  supra-nuclear  facial  palsy  is  associated  with  paralysis 
of  the  homolateral  arm  and  leg.  A  cortical  lesion  which 
involves  the  face  area  alone  is  of  theoretical  rather  than 
practical  interest. 

(iv.)  Herpes  of  the  external  auditory  meatus  may  be 
combined  with  facial  paralysis  and  is  then  supposed  to  be 
due  to  an  inflammatory  process  affecting  the  geniculate 
ganglion. 

VI.  The  Eighth  Cranial  Nerve.  The  eighth  nerve  is  made 
up  of  two  distinct  sets  of  fibres,  one  of  which,  the  vestibular 
nerve,  originates  in  the  vestibular  ganglion  and  terminates 
peripherally  in  the  sensory  epithelium  of  the  utricle,  saccule 
and  ampulla.  Centrally  these  fibres  end  m  the  vestibular 
nucleus,  whence  they  connect  with  Deiter"s  nucleus  and  so 
run  to  the  vermis  of  the  cerebellum.  They  are  concerned 
with  equilibration  and  form  one  of  the  main  afferent  cere- 
bellar paths. 

The  cochlear  nerve  is  the  true  nerve  of  hearing  and  arises 
in  the  spiral  ganglion  of  the  cochlea.  Peripherally  the  coch- 
lear fibres  terminate  in  the  organ  of  corti  ;  centrally  they 
run  to  the  cochlear  nucleus  in  the  cerebello -pontine  angle. 
From  the  cochlear  nucleus  two  routes  are  taken  : — ■ 

{a)  The  dorsal  portion  passes  under  the  floor  of  the  fourth 

ventricle  through  the  fillet  to  the  mferior  corpus  quadri- 

geminum  and  the  internal  geniculate  body  of  the  opposite 

side. 

(6)  The  ventral  portion  runs  through  the  base  of  the 

tegmentum  pontis  to  the  olive  and  thence  also  to  the 

opposite  corpus  quadrigeminum  and  geniculate  body. 


THE   CRANIAL   NERVES  501 

From  these  structures  the  final  auditory  path  runs  directly 
to  the  auditory  centre  in  the  superior  temporal  convolution. 

Lesions  of  the  vestibular  nerve  cause  a  cerebellar  type 
of  ataxy,  attacks  of  giddiness,,  and  a  tendency  to  fall  towards 
the  damaged  side. 

Lesions  of  the  cochlear  nerve  cause  nerve  deafness  which 
can  be  diagnosed  by  the  tests  of  Rinne,  Weber,  and 
.Schwabach. 

(i.)  Rinn6's  Test.  \\'ith  normal  hearing  it  is  possible  to 
hear  a  vibrating  tuning-fork  held  close  to  the  ear  after  all 
sound  has  ceased  to  be  perceived  with  the  butt  of  the  fork 
held  on  the  mastoid  process. 

In  nerve  deafness  the  same  effect  is  noticed,  but  in 
deafness  due  to  ear  disease  no  sound  is  heard  when  the  fork 
is  removed  from  the  mastoid  and  held  close  to  the  ear. 

(ii.)  Weber's  Test.  A  vibrating  tunmg-fork  is  held  against 
the  vertex  and  a  healthy  person  hears  the  sound  in  both  ears  : 
if  now  one  ear  is  stopped  up  he  hears  more  sound  in  the 
ear  so  stopped,  i.e.,  he  lateralises  to  the  side  on  which  air 
conduction  has  been  interrupted. 

A  patient  with  nerve  deafness  lateralises  of  his  own  accord 
to  the  sound  side,  but  one  who  is  deaf  from  ear  disease 
lateralises  to  the  side  of  the  deaf  ear. 

(iii.)  Schwabach' s  Test  is  of  great  service  when  deafness 
is  bilateral. 

The  test  consists  in  comparing  the  time  during  which 
(a)  the  patient  and  (6)  a  normal  person  can  hear  a  vibrating 
tuning-fork  which  is  held  to  his  vertex. 

In  nerve  deafness  the  length  of  tune  sound  can  be  heard 
by  '*bone  conduction"  is  diminished  or  even  absent;  in 
deafness  due  to  ear  disease  the  length  of  time  is  increased 
beyond  the  normal. 

Nerve  deafness  due  to  tumours  in  the  cerebello -pontine 
angle  or  in  the  sheath  of  the  nerve  is  associated  with  general 
signs  of  intracranial  tumour  and  also  with  paralysis  of 
neighbouring  nerves,  especially  the  fifth  and  seventh,  as 
well  as  cerebellar  signs,  such  as  nystagmus,  giddiness,  and 
ataxy. 

Nerve  deafness  may  occasionally  be  due  to  cortical 
lesions  on  the  left  side  affecting  the  superior  temporal  gyrus  ; 


502  MEDICAL  DIAGNOSIS 

more  commonly  word  deafness  only  is  the  result  of  such  a 
lesion. 

Meniere's  Disease,  {a)  Acute  Labyrinthitis.  This  is  due 
to  acute  inflammation  or  haemorrhage. 

The  symptoms  are  giddiness,  vomiting,  nystagmus  towards 
the  sound  side,  and  such  loss  of  equilibration  from  a  sense  of 
horizontal  rotation  that  recumbency  is  necessary. 

The  patient  is  only  comfortable  when  lying  on  the  sound 
side. 

The  acute  symptoms  generally  pass  oft"  within  a  week, 
(a)  Chronic   Labyrinthitis.     This    may   be    secondary    to 
very  chronic  middle-ear  disease  or  to  vascular  changes,  such 
as  arterio-sclerosis. 

In  the  former  variety  the  chief  symptoms  are  tinnitus 
and  middle-ear  deafness,  followed  after  a  distinct  interval  by 
paroxysmal  vertigo,  during  which  there  is  a  sense  of  rotation 
of  the  body  or  of  external  objects. 

In  the  latter  variety  there  is  also  tinnitus  and  paroxysmal 
vertigo,  and  practically  always  more  or  less  "  nerve  deafness," 
and  usually  a  tendency  to  vomit  after  the  attack  of  giddiness. 
Mild  cases  of  this  type  may  closely  resemble  "petit  mal," 
but  in  epilepsy  some  alteration  of  consciousness  is  the  rule, 
whereas  it  is  rare  in  labyrinthitis,  which  is  also  favoured 
by  demonstrable  nerve  deafness  and  the  occurrence  of 
vomiting. 

VII.  The  Ninth  and  Tenth  Cranial  Nerves.  The  glosso- 
pharyngeal and  vagus  are  in  reality  one  mixed  nerve, 
the  motor  part  of  which  springs  from  the  nucleus  ambiguus 
in  the  formatis  reticularis  of  the  medulla. 

The  sensory  parts  terminate  in  the  fasciculus  solitarius 
and  in  the  posterior  vago-glosso-pharyngeal  nucleus  in  the 
medulla. 

The  glosso-pharyngeal  nerve  does  not  appear  to  be  para- 
lysed by  itself  ;  when,  however,  it  is  affected  in  common 
with  other  nerves,  as  in  bulbar  paralysis,  the  symptoms  are 
difficulty  in  swallowing  from  ana3sthesia  in  the  pharynx 
and,  possibly,  loss  of  taste  for  the  posterior  third  of  the  tongue. 
The  stylo-pharyngeus  muscle  is  supplied  by  the  glosso- 
pharyngeal nerve,  but  paralysis  of  this  muscle  cannot  be 
recognised  clinically. 


THE   CRANIAL   NERVES  503 

The  vagus  nerve  supplies  the  pharj^nx,  oesophagus, 
larynx,  lungs,  heart,  stomach,  and  part  of  the  intestines, 
it  also  sends  branches  to  the  dura  mater  and  to  the 
skin  at  the  back  of  the  external  auditory  meatus. 

Hence  complete  bilateral  vagus  paralysis  is  immediately 
fatal.  If,  however,  only  one  vagus  is  affected,  there  is 
little  or  no  effect  on  the  heart's  action  or  on  the  respiration, 
and  the  most  notable  signs  are  unilateral  paralysis  of  the 
soft  palate  with  nasal  voice  and  complete  palsy  for  the 
half- larynx. 

The  recurrent  laryngeal  nerve  supplies  all  the  muscles 
of  the  larj'nx  except  the  crico-thyroid,  and  this  nerve  is  fre- 
quently affected  by  intra-thoracic  tumours.  The  result  is 
usually  an  abductor  paralysis  of  the  vocal  cord  on  the  left 
side.  It  is  noteworthy  that  double  adductor  paralysis  of 
the  vocal  cords  is  always  functional. 

VIII.  The  Eleventh  Cranial  Nerve  (the  Spinal  Acces- 
sory). The  bulbar  or  accessor}^  part  of  this  nerve  is 
simply  part  of  the  vagus  and  arises  from  part  of  the  vagus 
nucleus. 

The  Spinal  part  takes  origin  from  the  grey  matter  of  the 
cord  as  far  down  as  the  sixth  cervical  segment. 

This  nerve  supplies  the  sterno-mastoid  muscle  and  com- 
bines with  the  cervical  nerves  proper  to  supply  the  upper 
part  of  trapezius.  Disease  of  the  upper  two  cervical 
vertebrae  may  involve  this  nerve,  with  the  re&Tiit  that  the 
head  cannot  be  properly  turned  to  the  opposite  side  and 
the  shoulder  on  the  affected  side  cannot  be  shrugged,  and 
tends  to  "  drop." 

IX.  The  Twelfth  Cranial  Nerve  (the  Hypoglossal).  This 
nerve  arises  from  a  nucleus  in  the  dorsal  region  of  the  medulla 
and  emerges  from  the  anterior  surface  of  the  bulb  just 
external  to  the  pyramids. 

The  real  function  of  the  hypoglossal  nerve  is  to  supply 
the  muscles  of  the  tongue  ;  the  sterno-hyoid,  sterno -thyroid, 
and  omo-hyoid  are  supplied  through  the  anser  hypoglossi 
by  fibres  coming  from  the  upper  cervical  nerves. 

Paralysis  of  this  nerve  from  nuclear  or  infra-nuclear 
lesions  causes  wasting  and  wrinkling  of  the  corresponding 
part  of  the  tongue,  while  if  both  nerves  are  affected,  as  in 


604  MEDICAL   DIAGNOSIS 

bulbar  paralysis,  it  may  be  impossible  to  protrude  the  tongue 
at  all. 

In  supra-nuclear  lesions  there  is,  of  course,  no  wasting  and, 
probably  owing  to  bilateral  cortical  control,  the  deviation 
of  the  protruded  tongue  to  the  side  of  the  paralysed  limbs 
soon  passes  off. 

Nuclear  lesions  may  occur  in  bulbar  paralysis,  tabes, 
and  syringo-myelia. 

The  nerve  roots  are  frequently  involved  in  basal  meningitis, 
and  the  nerve  may  be  affected  peripherally  in  tumours  of 
the  neck. 


CHAPTER    m 

NEURITIS 

TiiE  periphercil  nerves  may  be  atfected  in  two  main  ways — 
first,  by  inteistitial,  and,  secondly,  by  parenchymatous 
inflammation. 

The  sheath  of  the  nerve  may  be  affected  (perineuritis), 
but  this  may  be  included  in  the  interstitial  group. 

The  above  classification  is  perhaps  rather  arbitrary  and 
may  be  misleadmg,  since  m  uiterstitial  neuritis  there  is 
secondary  parenchymatous  change  and  m  parenchymatous 
neuritis  the  interstitial  tissues  may  be  affected  also. 

I.  Interstitial  Neuritis  (Isolated  Neuritis).  This  usually 
affects  a  smgle  jnixed  nerve  trunk  and  may  result  from 
trauma  or  from  toxins  from  the  alimentary  tract,  or  it  may 
occur  in  the  course  of  prolonged  and  debilitating  disease, 
such  as  cancer  or  tuberculosis,  or  in  such  other  diseases  as 
syphilis,  rheumatism  and  gout,  and  lastly  by  jH'olonged 
pressure,  as  from  tumours  or  in  crutch  palsy. 
The  symptoms  are  : — 

(a)  Sensory,  varying  from  such  subjective  sensations  as 
tingling  or  numbness  to  severe  and  intractable  pain  in 
the  area  of  distribution  of  the  affected  nerve. 

(6)  Motor.  Partial  or  complete  flaccid  paralysis  of  the 
muscles  supplied  by  the  nerve,  with  loss  of  reflexes,  the 
reaction  of  degeneration,  and  later,  possibly,  contracture 
of  the  unparalysed  muscle  groups  in  the  neighbourhood, 
(c)  Trophic  and  Vaso-motor.  Thmning  and  glossiness 
of  the  skin,  atrophy  of  the  bones  and  loss  of  hair  and 
nails,  and  ulceration.  Frequently  there  is  over-activity 
of  the  vaso-motor  system  in  the  early  stages  and  cold, 
blue,  dry  skin  in  the  later. 

The  diagnosis  is  not  diflicidt  if  a  tender  nerve  trunk  can 
be  felt  and  if  the  sensory  disturbance  corresponds  to  the 
anatomical  distiibution  of  the  nerve.     As  stated  ])reviousIy. 


506  MEDICAL   DIAGNOSIS 

there  is  considerable  sensory  overlap,  so  that  the  actual 
area  of  sensory  disturbance  is  smaller  than  the  full  anatomical 
distribution  of  the  nerve,  and,  further,  the  area  of  proto- 
pathic  loss  is  negligible  if  cutaneous  nerves  alone  are  affected. 

In  all  cases  the  neighbouring  joints  must  be  carefuUy 
examined  to  exclude  the  muscular  paralysis  that  may 
follow  from  disuse  in  cases  of  arthiitis  :  the  electrical 
reactions  are  unaltered  in  these  cases. 

Certain  special  forms  of  interstitial  neuritis  may  be  dis- 
cussed separately  : — 

A.  Sciatica.  The  great  majority  of  cases  of  true  sciatica 
depend  on  a  perineuritis  somewhere  in  the  course  of  the 
sciatic  nerve.  The  disease  is  often  hereditary  and  appears 
to  be  connected  with  gout,  rheumatism,  and  exposure. 

The  symptoms  and  signs  are  : — 

{a)  Pain,  usually  dull  and  continuous  for  considerable 

periods,  along  the  course  of  one  sciatic  nerve  or  its  branches. 
(6)  Definite  tender  points  along  the  course  of  the  nerve, 

especially  over  the  sacro-sciatic  notch,  behind  the  great 

trochanter,  in  the  centre  of  the  posterior  aspect  of  the 

thigh,  behind  the  head   of    the  fibula,    and  behind  the 

external  malleolus. 

(c)  Definite  increase  of  the  pain  when  the  sciatic  nerve 

is  stretched  either  voluntarily  or  passive^. 

{d)  In  severe  cases  there  are  contractions  (flexion  at 

the  hip  and  knee,  with  the  toes  pointed  to  keep  the  heel 

off  the  ground)  and  also  muscular  wasting  and  more  or 

less  loss  of  epicritic  sensibility  over  the  outer  side  of  the 

foot  and  leg.     These  phenomena  of  course  depend  on  true 

neuritis  and  are  not  present  in  simple  sciatic  neuralgia. 

The  reflexes  are  preserved — indeed,  they  are  often 
brisk  unless  there  is  a  severe  secondary  parenchymatous 
neuritis. 

Sciatica  is  nearly  always  unilateral,  and  the  occurrence 
of  bilateral  sciatic  pain  should  excite  the  suspicion  of  the 
possibility  of  some  lesion  in  the  pelvis  or  cauda  equina. 

In  all  cases  of  apparent  sciatica  the  following  conditions 
must  be  carefully  excluded  : — 

(i.)  3Ialignant  Diseasf  of  the  Pelvic  Viscera.    Abdominal 

palpation    combined    with    digital    and    sigmoidoscopic 


NEURITIS  507 

examination  of  the  rectum,  etc.,  will  usually  ensure  a 
correct  diagnosis. 

(ii.)  Osteo-arthritis  of  the  Hip-Joint.  The  condition  is 
frequently  associated  with  sciatic  pain  and  can  nearly 
always  be  diagnosed  by  the  X-rays. 

(iii.)  Lesions  of  the  Cauda  Equina.  These  produce 
characteristic  segmental  sensory  disturbances,  flaccid 
motor  paralysis  of  muscles  supplied  by  the  particular 
roots  involved,  and  complete  incontinence. 

(iv.)   The   Lightning   Pains   of   Tabes    Dorsalis   can  be 

diagnosed  by  the  other  signs  of  this  disease. 

B.  Brachial   Neuritis.       This   appears   to   be    closely 

analogous  to  sciatica  :  the  pain  may  be  severe,  especially  in 

the  shoulder,  and  runs  down  the  arm  often  to  the  tips  of  the  first 

and  middle  fingers,  though  the  whole  hand  may  be  affected. 

Other  sensory  manifestations  may  vary  from  numbness 

and  tingling  in  the  extremities  to  peripheral  anaesthesia. 

Objective  sensory  loss  is,  however,  relatively  rare,  and  the 
same  applies  to  motor  symptoms,  though  slight  paresis  and 
wasting  may  be  found. 

The  diagnosis  of  brachial  neuritis  depends  on  the  exclusion 
of  the  following  conditions  : — 

(i.)  Aneurysm  or  cardiac  lesions  that  could  produce 
angina  pectoris  give  their  own  physical  signs. 

(ii.)  Osteo-arthritis  of  the  shoulder  and  also  of  the  spine 
can  be  excluded  by  the  X-rays. 

(iii.)  Cervical  rib  can  often  be  seen  by  the  X-rays  ;  it 
tends  to  give  a  forearm  paralysis,  with  special  wasting  of 
the  small  muscles  of  the  hand  owing  to  the  involvement 
of  the  lower  cord  of  the  brachial  plexus. 

(iv.)  Tabes  dorsalis  {vide  p.  544)  may  give  lightning 
pains  limited  to  the  arms. 

(v.)  Cervical  caries  can  be  detected  by  physical  examina- 
tion of  the  spine  aided  by  X-rays. 

(vi.)  New  growth  of  the  bones  forming  the  shoulder 
joint  can  usually  be  suspected  by  manipulation  and  con- 
firmed by  radiography. 

('.  The  Anterior  Crural  Nerve  may  be  affected  in  the 
same  way  as  the  sciatic  nerve;  a  tender  spot  can  often  be 
elicited  in  Scarpa's  triangle. 


508  MEDICAL   DIAGNOSIS 

II.  Parenchymatous  Neuritis  (Multiple  Neuritis).  This  is 
presumably  a  blood  infection  ;  it  is  symmetrical,  tends  to 
affect  many  nerves,  and  may  be  produced  by  many  poisons 
as  follows  : — 

(a)  Metallic  Poisons,  such  as  lead,  silver,  and  arsenic. 
{b)  Organic  Poisons,  such  as  alcohol,  carbon-bisulphide, 
and  carbon-monoxide. 

(c)  Toxins  of  Specific  Infective  Diseases ,  such  as 
diphtheria,  beri-beri,  measles,  septicsemia,  enteric  fever, 
influenza,  scarlet  fever,  gonorrhoea,  and  small-pox. 

(d)  Morbid  Blood  States,  such  as  cancer,  diabetes,  and 
anaemia. 

Since  the  clinical  picture  differs  somewhat  with  the  various 
toxic  products  which  are  the  cause  of  multiple  neuritis,  the 
following  varieties  may  be  described  briefly  : — 

(i.)  Alcoholic  Neuritis.     This  is  the  most  common  form 
of  polyneuritis  in  England.     It  affects  women  more  often 
than  men,  and  is  especially  frequent  in  the  secret  toper 
as  opposed  to  the  periodic  drunlcard. 
Three  clinical  varieties  are  described. 

(a)  The  Sensm-y  Type.  Numbness  and  tingling  are 
first  noticed  in  the  feet  and  later  in  the  hands.  These 
symptoms  give  way  to  or  are  later  accompanied  by  cramps 
in  the  calf  muscles,  which  become  so  severe  as  to  entail 
the  recumbent  position.  The  muscles  weaken  and  waste 
and  trophic  changes  appear  in  the  skm,  though  bed-sores 
are  rare.  The  feet  become  dropped  and  the  wrists  flexed, 
since  the  extensors  are  weaker  than  the  flexors. 

The  calf  muscles  are  conspicuously  tender. 

There  is  peripheral  diminution  of  all  forms  of  cutaneous 
sensibility  (sock  and  glove  anaesthesia). 

The  deep  reflexes  are  sluggish  and  finally  disappear. 

The  superficial  reflexes  are  sometimes  increased  at  the 
outset,  but  tend  to  become  diminished  later. 

The  sphincters  always  escape,  though  wilful  inconti- 
nence is  sometimes  met  with  in  those  cases  that  show 
marked  mental  change. 

The  cranial  nerves  nearly  always  escape,  though  the 
eye  muscles  show  easy  fatigue  and  sometimes  a  pseudo- 
nystagmus. 


NEURITIS  509 

Tremor  of  the  hands,  lips,  and  tongue  is  frequent. 
An  important  feature  is  the  tendency  (especially  in 
women)  for  a  curious  mental  change  to  supervene. 
This  is  known  as  Korsakow's  syndrome,  and  consists  in 
a  blunting  of  moral  sense  and  general  mental  inertia, 
combined  with  a  loss  of  memory  for  recent  events  and  a 
peculiar  lack  of  appreciation  of  time  and  place. 

(6)  The  Motor  Type.  The  earliest  symptoms  are  peri- 
pheral muscular  weakness  and  sense  of  easy  fatigue, 
while  a  "  high  stepping  '"  gait  is  often  adopted  to  prevent 
the  foot  dragging. 

Peripheral  paraesthesiae  are  usually  present,  though  not 
obtrusive,  but  muscle  tenderness,  especially  in  the  calves, 
is  characteristically  severe. 

The  reflex  system  behaves  as  m  the  sensory  form,  but 
trophic  changes  are  less  common  and  occur  later. 

(c)  The  Ataxic  Type.  The  most  striking  feature  of 
this  variety  is  a  loss  of  protopathic  sensation  as  shown  by 
inco-ordination  of  movements,  loss  of  sense  of  passive 
position,  and  muscular  hypotonus.  Romberg's  sign  is 
well  marked  in  these  cases. 

Muscular  tenderness  is  always  present,  and  this, 
together  with  the  retention  of  the  pupillary  light  reflex, 
serves  to  exclude  tabes  dorsalis. 

It  is  important  to  remember  the  liability  of  patients 
suffering  from  alcoholic  neuritis  to  suffer  from  cardiac, 
gastro-intestinal,  pulmonary,  and  renal  complications.  There 
is  also  a  special  tendency  towards  the  development  of 
serous  effusions,  so  that  it  may  be  stated  that  the  most 
urgent  risk  in  these  cases  arises  from  intercurrent  maladies, 
(ii.)  Arsenical  Neuritis  closely  resembles  the  alcoholic 
form  as  far  as  the  nervous  system  is  concerned  ;  it  may. 
however,  l)e  diagnosed  from  the  history  of  exposure  to  infec- 
tion, the  severe  gastro-intestinal  symptoms,  the  pigmenta- 
tion of  the  skin  (not  mucons  moinbranes),  and  the  cutaneous 
thickening  of  the  pahns  of  the  iiands  and  soles  of  the  feet 
(inrfe'also  p.  205). 

(iii.)  Lead  Neuritis.  Tiu*  motor  nerves  only  are  affected  ; 
the  arms  are  involved  earlier  and  more  severely  than  the 
legs,  while  in  many  oases  the  posterior  interosseous  nerve 


510  MEDICAL   DIAGNOSIS 

se^ns  to  be  exclusively  picked  out.  When  the  legs  are 
affected  the  anterior  tibial  muscles  are  usually  selected. 

A  di'opped  wTist  from  extensor  paralysis  is  thus  the  most 
conspicuous  feature,  though  very  often  tremor  of  the  hands 
may  be  the  earliest  sign. 

Other  evidence  of  lead  poisoning  can  usually  be  obtained 
[vide  p.  204). 

(iv.)  Diphtheritic  Paralysis.  It  is  probable  that  the 
parenchymatous  change  is  secondary  to  an  anterior  horn- 
cell  involvement. 

The  characteristic  selection  of  certain  muscle  groups  has 
been  described  on  p.  12. 

(v.)  Diabetic  Neuritis.  The  legs  are  always  affected 
earlier  and  more  severely  than  the  arms. 

Subjective  sensory  changes  are  slight,  so  that  the  condi- 
tion may  escape  notice,  but  investigation  shows  muscular 
tenderness  and  wasting,  ataxy,  and  sluggish  or  absent  re- 
flexes. 

The  presence  of  glycosuria  is  an  essential  point  in  the 
diagnosis  of  this  form  of  neuritis. 

(vi.)   Beri-beri  (vidJe  p.  116). 

III.  Acute  Toxic  Multiple  Neuritis.  The  toxins  of  certain 
specific  infections,  such  as  gonorrhoea  or  influenza,  as  well 
as  the  exanthems  and  other  less  definite  infective  disorders, 
may  occasionally  produce  an  acute  multiple  neuritis  charac- 
terised at  first  by  peripheral  sensory  parsesthesise.  These  are 
shortly  followed  by  muscular  paresis,  which  can  scarcely 
be  described  as  peripheral  rather  than  proximal,  so  extensive 
is  its  distribution.  The  trunk  and  face  are  often  involved 
in  this  motor  weakness. 

In  two  or  three  days  muscular  wastmg  is  apparent,  and 
by  now  objective  sensory  changes  have  developed  in  the 
direction  of  muscle  pains  and  tenderness  combined  with  a 
peripheral  loss  of  all  forms  of  sensibility. 

The  sensory  changes  serve  to  distinguish  this  condition 
from  Landry's  paralysis,  which  it  closely  resembles  in  its 
initial  stages. 


CHAPTER   IV 

LUMBAR  PUNCTURE  AND  THE  CEREBRO 
SPINAL  FLUID 

The  cerebro -spinal  fluid  is  secreted  by  the  choroid  plexuses ; 
it  fills  the  ventricles  of  the  brain  and  occupies  the  pia-arach- 
noid  space  at  the  base  of  the  brain  and  all  down  the  spinal 
cord.  The  fluid  gradually  drains  away  along  the  nerve 
roots  as  they  leave  the  spinal  column. 

The  cerebro-spinal  fluid  is  clear  and  watery  in  health  ; 
it  is  slightly  alkaline  and  contains  a  trace  of  globulin,  a 
trace  of  cholin,  a  trace  of  chlorides,  a  body  (glucose) 
which  reduces  Fehling's  solution,  and  one  or  two  lympho- 
cytes to  the  cubic  millimetre. 

An  examination  of  the  cerebro-spinal  fluid  is  often  of  the 
greatest  diagnostic  value.  The  fluid  is  obtained  by  lumbar 
pimcture,  which  is  performed  as  follows  : — ■ 

The  patient,  if  Avell  enough,  is  made  to  sit  on  the  edge  of 
the  bed  with  his  shouklcisbent  forwai'ds  as  fai-  as  ])().ssil)lf. 
If  the  patient  is  too  ill  to  sit  up  he  lies  on  his  side  and  again 
bends  forwards  as  much  as  possible.  Babies  must  be  forcibly 
tic.ved  by  ])ressiire  on  the  neck  and  l)nttocks. 

A  line  is  now  taken  joining  the  highest  points  of  the  iliac 
crests;  this  ])asses  through  the  middle  line  at  the  level  of 
the  spinous  j)i'ocess  of  the  fourth  lumbar  veitebi'a.  and  from 
this  landmark  the  third  or  t'outth  hnnbar  inter-\'ertebral 
spaces  can  be  Io(;ated.  The  skin  is  sterilised  and  a  stout 
needle  4  inches  long  is  passed  at  the  level  of  one  of  these 
spaces  (preferably  the  fourth)  and  |  inch  irom  the  middle 
line  in  a  direction  upward,  inwards,  and  forwards  till  the 
back  of  the  body  of  a  vertebra  is  felt  ;  the  needle  is  now 
withdrawn  \  inch  and  the  fluid  allowed  to  escape  by  its  own 
pressure. 

The  first  few  drops  may  be  neglected,  especially  if  blood- 


J512  MEDICAL   DIAGNOSIS 

stained,  but  the  rest  should  be  collected  in  a  sterile  vessel 
for  examination. 

The  diagnosis  of  the  following  diseases  may  be  simplified 
by  the  examination  of  the  cerebro-spinal  fluid  : — 

(i.)  Tuberculous  Meningitis.  The  fluid  is  under  pressure  ; 
it  is  clear  or  faintly  opalescent  ;  it  is  sterile,  and  shows  no 
organisms  ;  it  contains  a  considerable  excess  of  lympho- 
cytes (sometimes  several  hundred  per  cubic  millimetre)  ; 
there  is  sometimes  a  trace  of  albumin,  and  the  reducing 
body  is  diminished  but  not  often  absent. 

In  very  acute  cases  many  polymorphonuclear  leucocytes 
may  be  present  instead  of  lymphocytes,  and  exceptionally 
a  few  tubercle  bacilli  may  be  seen  in  films. 

(ii.)  Cerebi'o-Spinal  Meningitis,  Pneumococcal  Meni7igitis, 
and  Septic  Meningitis.  The  fluid  is  under  pressure,  turbid, 
contains  an  excess  of  polymorphonuclear  leucocytes,  definite 
albumin,  and  usually  shows  complete  absence  of  reducing 
body.  In  addition  the  appropriate  organisms  can  usually 
be  seen  in  the  films  and  cultivated  on  suitable  media. 

(iii.)  Hydrocephalus.  The  fluid  may  be  under  pressure, 
and  often  contains  much  albumin  but  no  cells. 

(iv.)  Cerebral  Syphilis.  The  fluid  contains  an  excess  of 
lymphocytes,  but  gives  a  negative  Wassermann  reaction 
in  over  70  per  cent,  of  cases. 

(v.)  Tabes  Dorsalis.  The  fluid  contains  an  excess  of 
lymphocytes  and  also  gives  a  positive  Wassermann  reaction 
in  60  per  cent,  of  cases.  The  globulin  content  is  markedly 
increased. 

(vi.)  General  Paralysis.  The  fluid  contains  an  excess 
of  lymphocytes  and  gives  a  positive  Wassermann  reaction 
in  95  per  cent,  of  all  cases.  The  globulin  content  is  markedly 
increased. 

(vii.)  Sleeping  Sickness.  The  trypanosomes  can  be 
demonstrated  in  films  of  the  cerebro-spinal  fluid  {vide 
p.  135). 


CHAPTER    V 
DISEASES  OF  THE  BRAIN 

I.  Hydrocephalus.  By  this  is  meant  damming  up  of 
cerebro-spinal  fluid  within  the  ventricles.  Hydrocephalus 
may  occur  as  a  congenital  abnormality  ;  it  may  develop 
spontaneously  at  any  time  ;  or  it  may  be  secondary  to 
intra-cranial  disease,  such  as  meningitis  or  tumour. 

(a)  The  Congenital  Type.  The  pathology  of  the  congenital 
form  is  not  known.  The  diagnosis  is  easy  and  can  be  made 
from  the  following  signs  :—  , 

(i.)  A  large  vault  to  the  skull  with  a  bulging  forehead 

overhanging  a  wizened  face  in  which  the  eyes  are  turned 

downwards. 

(ii.)  Patent  sutures  in  the  skull  and  prominent  veins 

in  the  scalp. 

(iii.)  Impaired    vision,     and    not    infrequently    optic 

atrophy. 

(iv.)  Fits  and  spastic  motor  paralysis. 

(v.)  Mental  deficiency,  should  the  child  live  long  enough 

for  this  to  be  recognised. 

(6)  The  Acquired  Type.  This  appears  to  be  due  to  an 
inflammation  of  the  cells  covering  the  choroid  plexuses. 

If  it  occurs  in  a  young  child  the  signs  will  be  much  as 
described  for  the  congenital  form  ;  if,  however,  it  does  not 
occur  until  the  growth  of  the  skull  has  finished,  the  diagnosis 
is  difficult.  The  classical  features  of  cerebral  tumour 
(headache,  vomiting,  and  optic  neuritis)  are  present  ;  but 
hydrocephalus  may  sometimes  be  suspected  by  the  occur- 
rence of  blindness  at  an  earlier  stage  than  is  usual  in  cerebral 
tumour — that  is  to  say,  while  the  neuritis  is  acute  and  before 
there  is  any  optic  atrophy,  by  the  early  impairment  of  the 
power  of  upward  movement  of  the  eyes,  by  the  impairment 
of  the  light  reflex,  by  the  fact  that  convulsive  attacks,  if 
present,  do  not  always  start  in  the  same  locality,  as  would  bo 

M.I).  33 


514  MEDICAL   DIAGNOSIS 

expected  in  tumour,  and  by  the  general  diffuse  spasticity  of 
the  limbs. 

(c)  Secondary  Hydrocephalus.  In  this  the  signs  of  the 
primary  lesion  rather  overshadow  the  signs  of  the  hydro- 
cephalus, though  in  cases  of  tumour  it  may  be  possible  to 
recognise  the  development  of  the  special  symptoms  described 
as  occurring  in  primary  hydrocephalus.  The  essential 
features  are  the  characteristic  visual,  oculo-motor  and  pupil- 
lary phenomena  and  the  bilateral  spasticity. 

II.  Vascular  Lesions,  {a)  Intra-cranial  Aneurysm.  Two 
forms  of  aneurysm  are  found  in  the  cerebral  blood-vessels — 
first,  multiple  or  miliary  aneurysms,  and,  secondly,  a 
single  aneurysm  of  definite  proportions. 

Miliary  Aneurysms  are  most  frequent  in  the  vessels 
supplying  the  basal  ganglia,  but  may  occur  anywhere  ; 
they  are  not  often  met  with  before  40  years  of  age  and  do 
not  give  rise  to  any  symptoms.  They  are,  however,  prone 
to  rupture  and  so  become  a  frequent  cause  of  cerebral 
haemorrhage. 

If  the  aneurysm  which  ruptures  is  situated  right  at  the 
base  of  the  brain  and  not  in  its  substance,  the  blood  rapidly 
infiltrates  the  pia-arachnoid  and  spreads  round  the  brain 
to  the  vertex,  often  without  ploughing  up  the  brain  sub- 
stance to  any  appreciable  extent.  In  such  cases  there  is 
little  resistance  to  continued  haemorrhage  and  the  rise  in 
intra-cranial  tension  is  very  rapid,  so  that  death  often  takes 
place  with  extreme  suddenness. 

Single  Aneurysms  do  not  give  rise  to  any  special 
symptoms  by  which  they  can  be  diagnosed  with  certainty. 
If  they  become  of  sufficient  size  there  may  be  both  general 
and  localising  signs  of  intra-cranial  tumour.  Any  other 
symptoms  that  may  be  present  can  only  be  referred  to  con- 
comitant arterio-sclerosis  of  the  cerebral  vessels, 

(6)  Cerebral  Hemorrhage.  It  seems  certam  that  a 
healthy  artery  will  not  rupture  no  matter  how  high  the  blood 
pressure  rises ;  therefore,  in  the  mechanics  of  cerebral 
haemorrhage,  one  must  postulate  a  damaged  vessel  in  addition 
to  a  raised  blood  pressure.  Occasionally  it  may  happen  that 
a  particular  vessel  is  so  diseased  as  to  rupture  with  a  sub- 
normal blood  pressure ;  but  such  cases  must  be  rare,  since 


DISEASES    OF   THE   BRAIN  515 

the  chief  cause  of  arterial  damage  is  high  blood  pressure, 
and  conversely  any  diffuse  arterial  lesion  is  likely  to  be 
followed  by  high  blood  pressure  to  compensate  for  impaired 
elasticity  in  the  walls  of  the  damaged  arteries. 

In  more  than  half  the  cases  of  cerebral  hsemorrhage  there 
is  a  history  of  previous  vascular  cerebral  troubles.  In  most 
cases  these  are  probably  thrombotic  in  nature,  and  the 
subsequent  haemorrhage  is  facilitated  by  the  lack  of  support 
to  the  vessels  which  results  from  softening  in  the  thrombotic 
area. 

Haemorrhage  may  occur  in  any  part  of  the  brain,  but  is 
most  common  at  the  base,  and  the  arteries  generally  affected 
are  the  lenticulo-striate  or  lenticulo-optic  branches  of  the 
middle  cerebral  artery. 

The  effect  of  a  haemorrhage  within  the  skull  is  that  of  a 
foreign  body  or  tumour,  but  one  that  has  developed  so 
quickly  that  no  compensatory  toleration  is  possible.  In 
addition  to  the  mechanical  destruction  of  nervous  elements, 
there  is  a  pressure  obliteration  of  veins  and  capillaries 
around  the  lesion  ;  this  causes  a  noteworthy  local  increase 
in  tension  (probably  to  the  height  of  the  arterial  pressure). 
Thus  the  symptoms  of  cerebral  haemorrhage  are  considered 
by  Leonard  Hill  to  be  due  to  compression,  which  is  itself 
the  result  of  cerebral  anaemia. 

Pursuing  this  argument,  it  is  obvious  that  the  danger  in 
these  cases  is  anaemia  of  the  medulla  oblongata,  and  that, 
in  fact,  this  bulbar  anaemia  is  the  cause  of  death  in  all  cases 
of  compression. 

Cerebral  haemorrhage  is  more  common  in  men  than  in 
women,  and  is  most  frequent  between  the  ages  of  45  and  55. 

There  may  be  premonitory  sjmptoms,  such  as  giddiness, 
throbbing  in  the  head,  headache  (sometimes  unilateral), 
or  epistaxis  ;  often,  however,  the  apoplectic  stroke  is  the 
first  sign. 

More  often  than  not  the  patient  becomes  unconscious  at 
once,  but  a  certain  number  of  cases  exhibit  convulsive 
attacks  for  a  varying  time  before  consciousness  is  lost. 

In  all  but  the  slightest  cases  the  coma  deepens  until  there 
is  a  compk'tely  flaccid  condition  of  all  four  limbs  with  absence 
of  all  reflexes.     The  pulse  is  slow  and  full,  the  breathing  is 

33—2 


516  MEDICAL   DIAGNOSIS 

stertorous,  and  at  this  time  it  is  impossible  to  tell  the  sound 
from  the  paralysed  side.  The  pupUs  may  be  unequal  ; 
that  on  the  side  of  the  brain  lesion  is  usually  the  smaller. 

The  great  majority  of  cases  of  cerebral  haemorrhage  end 
fatally,  often  within  a  few  hours,  from  rupture  of  the  effused 
blood-clot  into  the  lateral  ventricle.  When  this  rupture  takes 
place  unconsciousness  becomes  even  deeper,  there  is  often 
a  convulsion  and  vomiting,  the  temperature  rises  quickly, 
the  pupils  contract,  the  breathing  becomes  of  Cheyne- 
Stokes  type,  and  death  soon  ensues. 

Pontine  Hcemorrhage  is  usually  attended  by  very  sudden 
and  profound  unconsciousness,  though  sometimes  bilateral 
convulsions  are  noted.  There  is  a  bilateral  flaccid  paralysis 
and  usualty  a  high  temperature.  The  pupils  are  generally 
tightly  contracted,  but  towards  the  end  they  may  dilate 
and  assume  an  oval  outline.  Death  usually  occurs  in  from 
a  few  minutes  to  six  or  eight  hours. 

Cerebellar  Hcemorrhage  is  relatively  infrequent.  A  large 
haemorrhage  is  accompanied  by  unconsciousness,  but  not 
by  hemiplegia.  Vomiting  is  persistent  and  other  cere- 
bellar signs,  such  as  "  rotation  "  and  skew  deviation  of 
the  eyeballs,  may  be  noted.  Small  cerebellar  haemorrhages 
may  be  suspected  by  the  sudden  onset  of  cerebellar  symptoms 
in  a  person  free  from  internal  ear  disease. 

(c)  Cerebral  Thrombosis.  The  essential  factor  for  the 
occurrence  of  cerebral  thrombosis  is  vascular  degeneration, 
next  to  this  a  low  blood  pressure  and  feeble  heart,  and, 
lastly,  morbid  blood  states,  such  as  anaemia. 

Two  main  classes  of  case  can  be  recognised  clinically — 
first,  the  syphilitic,  in  which  a  thrombotic  hemiplegia  occurs 
between  the  ages  of  25  and  40  years  (often  within  six  years 
of  the  luetic  infection),  and,  secondly  the  old  and  debili- 
tated person  with  diseased  vessels,  feeble  circulation,  and 
low  blood  pressure. 

Thrombosis  tends  to  affect  the  same  vessels  as  haemorrhage 
with  the  noteworthy  addition  of  the  arteries  supplying  the 
temporo-sphenoidal  lobe. 

On  the  whole  it  may  be  stated  that  thrombosis  is  likely  to 
be  a  more  gradual  affair  than  hseiuorrhage,  but  this  pro- 
gressive train  of  symptoms  often  terminates  in  a  sudden 


DISEASES   OF   THE   BRAIN  517 

stroke  when  the  himen  of  the  vessel  becomes  completely 
blocked. 

As  m  haemorrhage,  many  of  the  premonitory  symptoms 
are  really  referable  to  general  arterio-sclerosis,  but  such 
symptoms  as  transient  numbness  or  paresis  may  be 
attributed  either  to  minute  focal  thrombosis,  or  more 
probabl}'  to  temporary  local  cerebral  anaemia  from  poor 
circulation  in  the  damaged  vessels. 

Headache,  drowsiness,  torpor,  and  giddiness  are  not 
infrequently  described  a  few  hours  before  the  absolute 
thrombosis  takes  place. 

Loss  of  consciousness  is  by  no  means  necessarj'  in  throm- 
bosis ;  it  may  be  absent  throughout,  or  it  may  develop 
insidiously,  keeping  pace  with  a  spreading  hemiplegia. 
Convulsions  are  less  frequent  than  m  haemorrhage. 

Such  localising  signs  as  may  be  present  depend  up6n  the 
particular  vessels  affected  :   for  example,  thrombosis  of — 
(i.)  The  middle  cerebral  artery  causes  complete  crossed 

hemiplegia   and   hemiansesthesia,   and   complete   aphasia 

(sensory  and  motor)  if  on  the  left  side. 

(ii.)  The^r*^  branch  of  the  left  middle  cerebral  artery  causes 

paralysis  of  the  opposite  face  and  tongue  as  well  as  motor 

aphasia. 

(iii.)  The   second  branch  of  the  middle  cerebral  artery 

causes  paralysis  of  the  opposite  face  and  arm. 

(iv.)  The    anterior    cerebral    artery    causes    progressive 

dementia. 

(v.)  The   basilar  artery  usually  causes  paralysis  of  all 

four  limbs  and  the  muscles  of  articulate  speech,  while 

not    infrequently  the  fifth,   sixth,   and    seventh   cranial 

nerves  are  involved  also. 

(vi.)  The  posterior  cerebral   artery   causes   hemianopia 

and  crossed  hemianaesthesia. 

(d)  Cerebral  Embolism.  Active  endocarditis  of  the 
left  heart  is  the  most  fie([uent  cause  of  cerebral  embolism  ; 
occasionally  it  may  follow  septic  pulmonary  conditions  {e.g., 
])ronehi('ftasis).  The  left  side  of  the  brain  is  more  often 
affected  than  the  right. 

The  onset  is  sudden,  and  convulsions  are  nuuh  more 
frequent  than  in  thrombosis  or  haemorrhage. 


518  MEDICAL  DIAGNOSIS 

The  localisation  is  the  same  as  discussed  under  "  Throm- 
bosis." As  a  rule  only  a  small  embolism  is  dislodged, 
so  that  the  infarcted  area  of  brain  is  small. 

The  diagnosis  depends  upon  the  recognition  of  a  cardiac 
or  (more  rarely)  pulmonary  lesion,  which  is  likely  to  be 
connected  with  embolism. 

(e)  Hemiplegia.  Paralysis  of  one  side  of  the  body  is 
the  usual  manifestation  of  an  apoplectic  stroke,  whether 
it  is  due  to  haemorrhage,  thrombosis,  or  embolism. 

The  recognition  of  hemiplegia  does  not  commonly  present 
much  difficulty,  but  at  first  (if  the  patient  is  profoundly 
unconscious)  it  may  not  be  easy  to  say  which  side  is  para- 
lysed, though  this  can  usually  be  recognised  by  lifting  the 
limbs  and  then  letting  them  drop,  when  the  complete  loss 
of  tone  on  the  paralysed  side  is  apparent. 

Since  the  lesion  is  an  upper  motor  neuron  one,  the  ultimate 
paralysis  will  be  of  spastic  type,  but  at  first  there  is  nearly 
always  complete  flaccidity  with  loss  of  all  reflexes.  Muscular 
rigidity  does  not  commonly  appear  for  two  or  three  weeks. 
After  the  shock  of  the  apoplexy  has  passed  off  the  deep 
reflexes  become  exaggerated  and  an  extensor  plantar 
response  appears.  As  degeneration  of  the  pyramidal  tract 
below  the  lesion  progresses,  the  spasticity  of  the  paralysed 
muscles  increases  until,  in  severe  cases,  the  characteristic 
hemiplegic  attitude  is  adopted.  This  attitude  consists  in 
adduction  of  the  upper  arm,  flexion  of  the  elbow,  flexion  and 
pronation  of  the  wrist,  and  flexion  of  the  fingers  and  thumb, 
the  thigh  is  adducted  at  the  hip,  the  knee  is  extended,  the 
foot  is  inverted  and  the  heel  is  raised  from  the  ground. 

Since  the  motor  cortex  of  one  side  is  often  cut  off  completely 
from  the  brain  stem  and  cord  in  cases  of  hemiplegia,  there  is 
an  apparent  anomaly  in  the  fact  that  the  trunk  muscles,  the 
ocular  muscles,  and  the  upper  part  of  the  face  escape  almost 
entirely.  The  explanation  is  that  these  muscles  are  accus- 
tomed to  synergic  action  with  their  fellows  of  the  opposite 
side  and  so  receive  a  bilateral  cortical  innervation.  The 
fact  that  emotional  movement  of  the  face  is  not  lost  to  the 
same  extent  as  voluntary  movement  depends  on  whether 
or  not  the  posterior  part  of  the  optic  thalamus  is  damaged. 

Recovery  of  power  in  those  who  survive  is  always  very 


DISEASES   OF   THE   BRAIN  519 

much  greater  than  the  extent  of  the  initial  paralysis  might 
lead  one  to  suspect  ;  the  leg  is  usually  less  affected  and 
recovers  more  completely  than  the  arm,  whilst  the  fine 
movements  of  the  hand  are  often  permanently  lost. 

A  certain  number  of  cases  exhibit  post-hemiplegic  athe- 
tosis (curious  spontaneous  movements  of  the  hands  and 
forearms,  consisting  in  repeated  rhythmical  hyper-extension 
of  the  digits  with  a  flexed  wrist).  Athetosis  is  rare  in 
adult  hemiplegias,  but  is  common  after  cerebral  paralyses 
of  children  ;  it  probably  depends  on  a  lesion  of  the  optic 
thalamus  and  indicates  that  no  further  recovery  is  likely. 

The  extent  and  distribution  of  the  paralysis  in  a  case  of 
hemiplegia,  as  well  as  the  presence  of  anaesthesia,  aphasia 
or  hemianopia,  depends  on  the  precise  situation  and  extent 
of  the  lesion  :    for  example — 

(i.)  Cortical  or  sub -cortical  lesions  are  likely  to  prx)duce 

a  restricted  paralysis  with  convulsions. 

(ii.)  Capsular  lesions  produce  a  complete  contra -lateral 

hemiplegia. 

(iii.)  Aphasia  can  only  be  produced    in    right-handed 

persons  by  a  left-sided  brain  lesion. 

(iv.)  Lesions  far  back  in  the  internal  capsule  produce  a 

hemianaesthesia  and  a  hemianopia. 

(v.)  Lesions  below  the  middle  of  the  pons  may  cause  a 

paralysis  of  the  contra -lateral   limbs   with   a  peripheral 

type  of  facial  palsy  on  the  side  of  the  lesion. 

(vi.)  Lesions  in  the  crus  may   cause   a   contra -lateral 

paralysis  of  limbs   and  lower  face   with   a  homolateral 

oculo-motor  palsy. 

Differential  Diagnosis.  In  attempting  to  diagnose  the 
cause  of  a  hemiplegia  a  general  and  comprehensive  review 
must  be  taken  of  the  case  as  a  whole.  The  possibility  of 
ura?mia  must  be  borne  in  mind  and  a  catheter  specimen  of 
the  urine  examined  for  casts  and  albumin.  The  fundus 
oculi  may  show  albuminuric  retinitis,  and  it  is  noteworthy 
that  a  retinal  haemorrhage  often  occurs  shortly  before  cerebral 
haemorrhage  and  thrombosis. 

Marked  optic  neuritis  might  suggest  the  possibility  of  a 
cerebral  tumour,  haemorrhage  into  which  may  cause  a  sudden 
hemiplegia.     Examination  of  the  heart  should  be  made  to 


520  MEDICAL     DIAGNOSIS 

exclude  embolism,  and,  if  there  is  marked  hypertrophy, 
will  confirm  a  diagnosis  of  chronic  nephritis  and  so  favour 
to  some  extent  a  diagnosis  of  haemorrhage. 

The  state  of  the  arteries  and  the  blood  pressure  must  be 
determined,  though  it  must  be  remembered  that  any  sudden 
intra-cranial  disturbance  is  likely  to  be  accompanied  by  an 
increased  blood  pressure,  so  that  a  high  blood  pressure, 
per  se  by  no  means  excludes  thrombosis. 

The  history  of  the  manner  in  which  the  stroke  occurred 
is  all-important  when  it  can  be  obtained  ;  the  slower  the 
onset  and  the  slighter  the  damage  the  greater  the  probability 
of  thrombosis.  If  there  is  little  or  no  loss  of  consciousness, 
haemorrhage  is  unlikely,  while  the  younger  the  patient  the 
more  probable  is  it  that  the  lesion  is  thrombotic  ;  and  again, 
the  very  old  and  feeble  are  more  liable  to  thrombosis  than 
to  haemorrhage. 

Lastly,  two  facts  should  be  borne  in  mind- — first,  the  great 
majority  of  cases  of  hemiplegia  are  due  to  thrombosis  ; 
and,  secondly,  the  great  majority  of  cases  of  cerebral 
haemorrhage  are  quickly  fatal. 

When  a  patient  is  seen  for  the  first  time  in  a  state  of 
profound  unconsciousness  and  no  reliable  history  can  be 
obtained  it  may  not  be  possible  to  demonstrate  conclusively 
that  the  condition  is  one  of  hemiplegia,  and  the  following 
possibilities  must  not  be  overlooked  : — 
(i.)  Uraemic  Coma, 
(ii.)  Diabetic  Coma, 
(iii.)  Alcoholic  Poisoning, 
(iv.)  Narcotic  Poisoning, 
(v.)  Cerebral  Tumour  or  Abscess. 

Urcemia  or  Diabetes  are  suggested  by  an  examination 
of  the  urine  as  well  as  by  the  smell  of  the  patient. 

Alcoholism  gives  dilated,  equal  pupils,  and  the  patient 
can  usually  be  roused  by  shouting  or  pinching  the  neck  ; 
his  breathing  is  slow,  deep  and  regular,  but  very  rarely 
stertorous. 

Narcotic  Poisoning  (opium,  etc.)  often  gives  a  smell  of 
the  drug  used,  the  pupils  are  pin-point  and  equal  ;  the 
patient  can  sometimes  be  roused  temporarily  by  shouting. 

Cerebral   Tumour  or  Abscess  is  suggested  by  a  choked 


DISEASES   OF   THE   BRAIN  521 

disc,  while  abscess  may  possibly  be  suggested  by  otitis 
media. 

(/)  Local  Cerebral  Anemia.  When  the  cerebral  arteries 
are  greatly  diseased  the  circulation  through  them  becomes 
much  hampered,  with  the  result  that  a  temporary  lowering 
of  blood  pressure  may  cause  a  corresponding  anaemia  of 
that  part  of  the  brain  which  is  supj)liedby  the  most  degene- 
rate vessels. 

In  this  fact  lies  the  explanation  of  those  cases  of  transient 
hemi-  or  mono-plegia  or  aphasia  which  often  last  but  a  few 
hours  and  then  recover  completely. 

The  recognition  of  these  cases  is  important,  for  they  are 
especially  likely  to  be  followed  by  a  real  thrombotic  attack 
sooner  or  later,  and  much  can  be  done  by  judicious  treat- 
ment to  ward  off  such  a  disaster. 

III.  Cerebral  Palsies  of  Infancy  and  Childhood.  AJl  the 
factors  which  cause  hemiplegia  in  adults  produce  similar 
lesions  in  children  :  haemorrhage,  however,  is  peculiarly 
rare  ;  embolism  is  much  more  common,  since  ulcerative 
endocarditis  is  not  infrequent  in  children  ;  thrombosis  is 
not  often  seen,  but  may  occur  in  association  with  any  severe 
marantic  disorder.  It  is  probably  the  principal  cause  of 
the  rare  condition  known  as  "  porencephaly,"  when  as  the 
result  of  softening  and  subsequent  growth  of  skull  and  brain 
large  cyst-like  cavities  may  be  formed  in  the  brain  sub- 
stance. 

Apart  from  the  above,  infantile  cerebral  palsies  may  be 
divided  into  two  groups — congenital  and  acquired. 

(a)  Congenital  Cerebral  Diplegia.  This  condition 
results  from  imperfect  development  of  one  or  more  neuron 
systems  in  the  brain  ;  the  causes  are  quite  unknown,  though 
sometimes  there  is  a  familial  tendency,  but  the  signs  may 
be  present  at  birth  or  (more  rarely)  may  not  develo])  until 
later. 

A  bilateral  spastic  paresis  is  present,  and  tiiis  may  affect 
the  face  and  all  four  limbs.  Both  sides  of  the  body  need 
not  be  equally  affected. 

Mental  deficiency  to  a  greater  or  less  extent  is  practically 
always  found. 

Optic   atrophy   is   a  fairly   common   accompaniment,    as 


522  MEDICAL  DIAGNOSIS 

is  nystagmus,  and  other  cranial  nerves  are  sometimes 
affected. 

The  spasticity  is  often  so  marked  that  progression,  when 
possible  at  all,  is  frequently  by  means  of  the  "  cross-legged  " 
or  "  scissor  "  gait. 

Athetoid  movements  of  the  hands  and  arms  are  nearly 
always  a  prominent  feature  of  these  cases,  and  probably 
depend  on  lesions  of  the  optic  thalamus  or  its  connections. 

(6)  Acquired  Cerebral  Palsies,  (i.)  Birth  Palsies. 
These,  as  the  name  denotes,  are  the  result  of  injury  at  birth, 
sometimes  by  the  blades  of  the  forceps  used  in  delivery. 

The  more  permanent  and  severe  forms  are  usually  the 
result  of  meningeal  haemorrhaige  produced  in  this  manner. 

(ii.)  Encephalitis.  This  is  by  far  the  most  common  form 
of  acquired  cerebral  paralysis  in  infancy  or  childhood,  and 
if  the  congenital,  embolic,  and  thrombotic  forms  can  be 
excluded  it  is  the  probable  cause  of  all  such  cases. 

Encephalitis  is  an  acute  but  non-suppurative  inflammation 
around  the  blood-vessels  of  the  cerebral  cortex.  The 
micro-organism  which  causes  this  is  the  same  as  that  which 
causes  acute  poliomyelitis  in  the  cord,  the  only  difference 
being  the  regions  affected. 

The  most  common  age  for  encephalitis  is  up  to  three  years. 

The  symptoms  are  those  of  any  acute  infection  ;  vomiting, 
pyrexia,  and  always  convulsions  ;  the  majority  of  patients 
lose  consciousness,  and  coma  may  last  for  days  or  even 
weeks. 

As  the  acute  stage  passes  off  more  or  less  paralysis  becomes 
evident,  and  this  is  of  the  upper  motor  neuron  type.  Perhaps 
the  most  common  form  is  a  hemiplegia  or  diplegia,  but  it 
is  obvious  that  any  variety  and  extent  of  cerebral  paralysis 
may  be  met  with,  since  any  part  or  all  of  the  brain  may  be 
affected.  Athetoid  movements  are  common  in  the  cases 
in  which  permanent  paralysis  ensues. 

Whether  any  of  the  paralysis  is  permanent  or  not  depends 
on  whether  the  inflammation  was  severe  enough  completely 
to  destroy  the  nerve  cells. 

A  very  large  proportion  of  children  who  have  encepha- 
litis become  epileptic  in  later  years,  the  epilepsy  often 
being  rather  of  Jacksonian  type,  in  so  far  as  the  convulsions 


DISEASES   OF   THE   BRAIN  523 

are  chiefly  seen,  or.  at  any  rate,  nearly  always  commence  in 
the  same  place,  that  is  to  say,  the  paralysed  limb. 

IV.  Tumours  of  the  Brain.  In  children  tuberculomas  are 
the  most  common  variety  of  cerebral  tumour  ;  in  adults 
gliomas  are  more  frequently  present,  and  are  followed  in 
diminishing  order  of  frequency  by  sarcomas,  endotheliomas, 
tuberculomas,  gummas,  and  carcinomas. 

Cysts  (echinococcal  or  cysticereal)  may  occur  in  connection 
with  the  ventricles,  but  are  rarely  seen  in  England. 

Intra -cranial  tumours  can  be  divided  into  two  main  groups 
according  to  their  anatomical  position— first,  supraten- 
torial  or  anterior,  and,  secondly,  infra -tentorial  or  posterior. 
The  former  are  most  common  in  adults,  the  latter  in 
children. 

Apart  from  special  localising  signs  which  will  be  mentioned 
later,  it  may  be  stated  that  tumours  of  the  anterior  chamber 
give  rise  to  mental  symptoms  very  much  earlier  and  more 
frequently  than  those  of  the  posterior  chamber,  and  also  that 
optic  neuritis  may  more  often  be  recognised  as  commencing 
on  the  side  of  the  tumour  in  these  cases. 

The  earliest  sign  of  a  tumour  in  the  anterior  chamber 
may  be  a  loss  of  the  superficial  abdominal  reflex  and  a 
tendency  to  briskness  of  the  deep  reflexes,  on  the  opposite 
side  of  the  body.  Later  on  many  of  these  cases  give  a 
contra -lateral  extensor  plantar  response. 

In  tumours  of  the  posterior  chambers  the  spinal  canal 
gets  shut  off  from  the  cranium  by  the  formation  of  a  pressure 
cone,  which  forces  the  medulla  into  the  foramen  magnum 
earlier  than  in  the  anterior  chamber  tumours,  with  the  result 
that  internal  hydrocephalus  is  more  usual  in  these  cases 
and  failure  of  the  medullary  cardiac  and  respiratory  centres 
is  a  more  imminent  danger.  The  deep  reflexes  may  be 
brisk  in  the  case  of  posterior  chamber  tumours,  but  the 
superficial  are  usually  unaltered. 

The  signs  and  symptoms  of  brain  tumours  are  divided  into 
two  groups — (i.)  General,  and  (ii.)  Localising. 

(i.)  General  Symptoms — (a)  Headache.  This  is  probably 
the  most  constant  symptom — it  need  not  be  continuous,  and 
indeed  may  cease  with  extreme  suddenness  from  time  to 
time.     The  character  of  the  pain  varies — sometimes  it  is 


524  MEDICAL   DIAGNOSIS 

lancinating,  at  others  a  dull  ache.  The  situation  of  the  pain 
is  of  but  little  value  as  a  localising  sign,  though  an  occipital 
pain  suggests  a  cerebellar  rather  than  a  cerebral  tumour. 

(6)  Vomiting.  This  is  not  such  a  constant  feature  as 
headache  ;  in  its  typical  form  it  occurs  quite  suddenly 
without  nausea  or  pain  and  independently  of  food. 

(c)  Optic  Neuritis.  This  is  the  result  of  the  cerebro- 
spinal fluid  being  forced  by  the  increasmg  pressure  into  the 
sheaths  of  the  optic  nerves.  It  develops  early  in  tumours 
of  the  cerebellum,  later  and  more  gradually  in  tumours  of 
the  cerebrum,  and  is  not  infrequently  absent  in  tumours 
of  the  pons  unless  the  ventricles  themselves  become 
obstructed  by  the  growth. 

{d)  Giddiness.  This  may  frequently  accompany  periodic 
attacks  of  headache  and  vomiting. 

(e)  Mental  Symptoms.  These  are  commonly  present  in 
tumours  of  the  anterior  chamber  when  the  increased  tension 
has  become  communicated  to  the  opposite  cerebral  hemi- 
sphere. Irritability  of  temper  and  mental  hebetude  are 
perhaps  the  most  usual  signs.  Of  course  a  frontal  tumour 
may  give  psychical  symptoms  as  its  earliest  phenomena  if 
such  can  be  recognised. 

(/)  Convulsions.  These  vary  from  sensations  of  faintness 
to  typical  epileptiform  seizures  (Jacksonian  or  generalised), 
and  are  present  in  a  fair  proportion  of  cases,  especiall}^ 
when  the  tumour  is  above  the  tentorium. 

(ii.)  Localising  Signs. — [a)  Frontal  Tumours.  The  head- 
ache is  sometimes  frontal  ;  optic  neuritis  appears  late  and 
is  most  marked  on  the  side  of  the  growth.  Mental  symptoms 
of  all  kinds,  from  lack  of  power  of  concentration  to  delu- 
sional insanity,  are  very  liable  to  be  present. 

Convulsive  attacks  may  start  with  jerking  movements 
of  the  head  and  eyes  to  the  opposite  side  ;  generalised 
convulsions  with  loss  of  consciousness  may  follow,  but  are 
not  inevitable. 

Attacks  of  pure  motor  aphasia,  in  which  the  patient  utters 
unintelligible  jargon,  may  occur  in  left-sided  frontal  tumours 
either  alone  or  as  precursors  of  general  convulsions.  Though 
the  convulsive  attacks  may  closely  resemble  epilepsy  there 
is  never  a  sensory  aura. 


DISEASES   OF   THE   BRAIN  525 

(6)  Tumours  of  the  Motor  Area.  The  general  signs  of 
tumour  are  usually  well  marked. 

The  localising  signs  are  principally  convulsive  attacks 
whose  commencement  is  local  but  which  become  general 
later  ;  in  the  later  stages  such  irritative  phenomena  always 
give  way  to  signs  of  spastic  paralysis  in  the  contra -lateral 
limbs  and  face.,  according  to  the  particular  motor  cells 
affected. 

If  the  tumour  is  sub -cortical  the  convulsive  attacks  are 
less  liable  to  occur. 

Both  psychic  and  sensory  signs  may  well  be  present  also, 
owing  to  the  propinquity  of  the  centres  for  these  functions 
to  the  true  motor  area. 

(c)  Tinnoiirs  of  the  Sensory  Area.  In  addition  to  the 
general  signs  of  tumour,  there  may  be  loss  of  sense  of  move- 
ment (active  and  passive)  and  loss  of  tactile  sensiKility. 
These  losses  are  contra-lateral  and  most  evident  in  the 
peripheral  part  of  the  limbs,  and  do  not  follow  the 
segmental  or  the  cutaneous  distribution  of  the  sensory 
nerves. 

The  remaining  sensory  appreciations  may  be  affected 
little  or  not  at  all. 

(,'onvulsive  attacks  are  Jacksonian  in  type  and  correspond 
to  the  adjacent  precentral  motor  centres  ;  they  are  preceded 
by  local  numbness  and  tingling,  which  shows  that  the  dis- 
turbance commences  in  the  post-central  area. 

{d)  Tumours  of  the  Occipital  Region.  The  general  symp- 
toms are  present  ;  the  headache  is  often  occipital  and  the 
optic  neuritis  is  often  acute. 

The  localising  signs  are  homonymous  visual  disturbance, 
culminating  in  hemiano])ia.  The  early  signs  arc  subjective 
and  may  simulate  migraine.  If  the  tumour  grows  forwards 
both  word  blindness  (from  involvement  of  the  angular 
gyrus)  and  homi-ana*sthesia  (from  involvement  of  the 
posterior  part  of  the  internal  capsule)  nuiy  develop. 

Convulsions,  if  present,  may  have  a  visual  aura. 
{e)  Tumours  of  the  Temjporo-sphenoidal  Lobe.    The  general 
symptoms  are  usually  present,  but  are,  perhaps,  less  constant 
than  in  the  regions  already  dealt  with. 

It  may  he   im])()ssil)le  to   localise  a  cerel)ral   tumour  in 


526  MEDICAL   DIAGNOSIS 

the  tempore -sphenoidal  lobe,  but  if  certain  parts  of  the  lobe 
are  involved  the  following  signs  may  be  present  : — 

(i.)  Seizures  or  convulsions  starting  with  an  aura  of 
smell  (and  usually  an  unpleasant  smell)  suggest  a  lesion 
of  the  uncinate  lobe.  Temporary  loss  of  both  smell  and 
taste  may  follow  the  attacks. 

(ii.)  Subjective  sensations  of  sound  suggest  lesions  of  the 
superior  temporal  gyrus  ;  if  convulsions  occur  they  may 
be  limited  to  the  opposite  face  and  arm  and  may  be 
followed  by  incomplete  deafness  in  the  opposite  ear. 

If  the  lesion  is  on  the  left  side  word  deafness  may  be 
present. 

(/)  Tumours  of  the  Mid- Brain.    In  addition  to  the  general 
signs  the  following  localising  signs  may  be  present : — 

(i.)  Contra-lateral  hemiplegia,  sometimes  hemi-anees- 
thesia,  and  sometimes  bilateral  motor  paralysis. 

(ii.)  Contra-lateral  ataxy  and  rhythmical  tremor. 

(iii.)  Defective  light  reflex  and  eccentric  pupils. 

(iv.)  Weakness  of  upward  movement  of  eyeballs. 

(v.)  Paralysis  of  third  and  fifth  cranial  nerves. 
{g)   Tumours  of  the  Pons.     General  symptoms  are  striking 
in  their  absence  or  late  appearance  ;   this  is  due  to  the  fact 
that   a  slow-growing,  diffuse  glioma  is  the  most  common 
new  growth  in  this  region. 

The  localising  signs  may  be — • 

(i.)  Optic  Atrophy  without  previous  optic  neuritis  ;  this 
is  produced  by  pressure  on  the  chiasma  by  a  distended 
third  ventricle. 

(ii.)  Paralysis  of  the  fifth  and  twelfth  cranial  nerves. 

(iii.)  Eccentric  pupils. 

(iv.)  Bilateral  spastic  paralysis,  accompanied  by  ataxy. 

(v.)  Shivering  attacks. 

(vi.)  Hemi-ansesthesia  (not  constant). 

(vii.)  Progressive  hydrocephalus  is  frequently  observed 
in  children  who  have  pontine  tumours. 
[h)  Tumours  of  the  Cerebellum. 

(i.)  Intra-cerebellar  Tumours  (lateral  lobe).  With  the 
exception  of  mental  symptoms  and  convulsions,  the  general 
signs  of  intra-cranial  tumour  are  prominent :  the  head- 
ache is  severe,  often  occipital,  and  sometimes  extending 


DISEASES   OF   THE   BRAIN  527 

down  the  neck.  Optic  neuritis  appears  early  and 
advances  very  rapidly  in  both  eyes.  Giddiness  is  frequent, 
and  generally  there  is  a  sensation  that  both  the  patient 
and  external  objects  are  rotating  away  from  the  side  of 
the  lesion.  Nystagmus  is  always  present ;  occasionally 
there  is  skew  deviation  of  the  eyeballs,  but  this  is  usually 
transient. 

The  nystagmus  is,  as  a  rule,  only  present  on  conjugate 
lateral  movement  ;  the  movements  are  slow  and  deliberate 
(coarse)  towards  the  side  of  the  lesion,  fine  and  hurried 
towards  the  opposite  side. 

The  remaining  cranial  nerves  are  not  specifically 
affected,  except  possibly  the  external  rectus  on  the  side 
of  the  lesion,  which  may  show  slight  paresis. 

Motor  symptoms.  There  is  slight  general  muscular 
paresis  and  distinct  loss  of  muscle  tone  on  the  side  of  the 
lesion.  There  is  ataxia  on  the  side  of  the  lesion.  This 
results  from  loss  of  co-ordinating  power  for  synergic 
movements  ;  it  is  only  present  on  movement  and  is  most 
obvious  in  the  trunk  and  legs. 

The  gait  is  reeling,  and  the  patient  tends  to  fall  to  the 
side  of  the  lesion  ;  to  correct  this  he  often  rotates  his 
body  to  the  sound  side,  with  the  result  that  he  may 
over-correct  and  so  appear  to  stumble  to  the  sound  side. 
The  attitude  may  be  suggestive  ;  the  shoulder  on  the 
side  of  the  lesion  is  raised  and  the  occiput  tilted  down 
towards  the  raised  shoulder,  so  that  the  chin  is  turned 
slightly  upwards  and  outwards  towards  the  sound 
side. 

Sensory  symptoms.     These  are  absent. 

Reflexes.  The  superficial  reflexes  are  unaltered.  The 
deep  reflexes  tend  to  be  brisk,  but  there  is  not  an  extensor 
plantar  response  unless  there  is  secondary  pressure  on 
the  pyramidal  tract. 

(ii.)  Intra-cerebellar  Tumours  (middle  lobe).  In  these 
cases  there  is  no  lateralisation  of  symptoms.  The  ten- 
dency is  to  fall  forwards  or  backwards  ;  the  nystagmus 
is  equal  to  either  side,  and  the  motor  symptoms  are 
bilateral. 

Owing  to  the  proximity  of  the  fourth  ventricle  spas- 


528  MEDICAL  DIAGNOSIS 

ticity,   tremors,   internal  hydrocephalus,   and   glycosuria 
may  be  added  to  the  more  definite  cerebellar  signs. 

(iii.)  Tumours  of  the  Cerebello-pontine  Angle.  The 
eighth  cranial  nerve  is  usually  the  site  of  origin  for  these 
tumours.  They  grow  very  slowly,  and  may  give  rise  to 
no  signs  till  they  press  upon  the  cerebellum  and  pons. 
Hence  headache  appears  late,  and  optic  neuritis  may  be 
absent  or  inconspicuous  for  a  long  time. 

The  fifth,  sixth,  seventh,  and  eighth  cranial  nerves  are 
very  likely  to  be  affected  before  there  are  general  signs 
of  intra-cranial  tumour.  Nerve  deafness  is  often  the 
first  sign  and  facial  paralysis  the  second. 

When  pressure  is  definite  on  both  pons  and  cerebellum 
the  signs  are  likely  to  be  those  of  a  homolateral  cerebellar 
lesion   combined   with   a   contra-lateral  spastic  paralysis 
from  involvement  of  the  pyramidal  fibres  in  the  pons. 
The  sensory  system  usually  escapes  entirely. 
The  reflexes  are   important  because  the  deep  reflexes 
are  increased,  but  especially  so  on  the  opposite  side  to 
the  lesion,  where  also  an  extensor  plantar  response  is 
found.     The  superficial  reflexes  are  absent  on  the  oppo- 
site side  and  quite  brisk  on  the  side  of  the  lesion. 
The  combination  of   spasticity  on  one    side   and   ataxia 
on  the  other  is  sufficiently  striking  to  suggest  the  diagnosis. 
It  is   stated    that    these  cases  differ  from  intra-cerebellar 
tumours  in  the  apparent  direction  of  rotation  of  the  patient 
during  the  vertiginous  attacks.     In  intra-cerebeUar  lesions 
it  will  be  remembered  that  the  external  objects  appear  to 
rotate  towards  the  sound  side,  as  does  the  patient  himself, 
but  in  extra-cerebellar  tumours  the  external  objects  rotate 
from  the  affected  side  to  the  sound  side  as  before,  although 
the  patient  feels  as  if  he  himself  were  rotating  towards  the 
side  of  the  lesion. 

V.  Abscess  of  the   Brain.     This  may  be  caused  in  the 
following  manners  :— 

(i.)  Trauma  of  the  scalp  or  skull,  and  in  this  connection 
it  is  necessary  to  remember  that  direct  injury  of  the  brain 
or  even  fracture  of  the  skull  are  not;  essential  antecedents 
to  the  formation  of  an  abscess  in  the  brain. 

(ii.)  Suppuration  in  the  middle  or  internal  ear  ;    the 


DISEASES   OF   THE   BRAIN  529 

former   is    most   likely   to    cause    a    temporo-sphenoidal 

abscess,  the  latter  a  cerebellar  abscess. 

(iii.)  Suppurative    processes    within    the    nose,    naso- 
pharynx, and  accessory  sinuses  ;    these  are  more  likely 

to  produce  a  purulent  basal  meningitis,  but  may  cause  a 

frontal  abscess  also. 

(iv.)  Local    septic    processes    (non-traumatic)    of    the 

scalp  and  skull — for  example  erysipelas. 

(v.)  General  infections,  such  as  septicaemia  and  more 

rarely  the  exanthems. 

(vi.)  Septic  pulmonary  conditions,  such  as  bronchiec- 
tasis and  empyema. 

Brain  abscess  may  be  acute  or  chronic  according  to  the 
virulence  and  nature  of  the  causative  organisms. 

The  temporo-sphenoidal  lobe  is  affected  more  frequently 
than  all  the  other  parts  of  the  brain  put  together,  arfd  the 
cerebrum  is  affected  about  twice  as  often  as  the  cerebellum. 

The  general  symptoms  of  brain  abscess  are  in  the  main 
those  of  brain  tumour,  with  the  possible  differences  that 
mental  symptoms  are  early  and  very  constant  and  optic 
neuritis  absent  or  late  in  appearing. 

The  temperature  is  variable  ;  in  many  cases  it  is  subnormal 
throughout  or  untU  the  abscess  bursts  into  the  lateral 
ventricle. 

High  pyrexia  is  exceptional. 

The  pulse  is  slow  and  regular,  even  when  there  is  distinct 
fever. 

The  initial  mental  symptoms  of  irritability  and  emotional 
instability  gradually  pass  into  mental  hebetude  and  drowsi- 
ness, and  eventually  into  coma. 

The  cerebro-spinal  fluid  may  show  an  excess  of  polymor- 
phonuclear leucocytes  and  even  organisms,  though  the 
presence  of  these  would  suggest  a  coincident  meningitis. 

In  diagnosing  either  the  pre.'^ence  or  position  of  a  brain 
abscess  a  most  important  point  is  the  existence  of  one  of 
the  conditions  enumerated  above  as  likely  to  be  followed  by 
abscess  ;  for  the  rest  the  localising  signs  are  very  much 
those  described  under  "  Intra-cranial  Tumour."'  We  may 
again  emphasise  the  early  loss  of  the  opposite  superficial 
abdominal  reflex   in   cerebral   abscess.     Retraction   of  the 

M.I).  34 


530  MEDICAL   DIAGNOSIS 

head  and  paiii  down  the  neck  are  frequently  seen  in  cerebellar 
abscess,  and  it  is  stated  that  one  of  the  earliest  signs  of 
left  temporo-sphenoidal  abscess  is  the  inability  of  the  patient 
to  name  objects  even  though  he  knows  their  functions  (one 
form  of  auditory  aphasia). 

VI.  Aphasia.  The  art  of  speech  is  acquired  coincidently 
with  the  development  of  certain  centres  m  the  brain.  In 
right-handed  persons  these  centres  are  situated  in  the  left 
cerebral  hemisphere.  These  special  centres  permit  of  the 
storing  up  of  visual  impressions,  that  is,  impressions  of 
objects  seen  and  also  auditory  impressions,  that  is,  the 
sound  of  words  heard.  In  addition  to  these  there  must 
be  a  centre  for  the  reception  of  impressions  of  the  muscular 
movements  concerned  in  the  production  of  certain  sounds, 
by  means  of  which  are  correlated  the  sound  of  a  word  and 
the  movements  of  the  articulatory  muscles  necessary  to 
produce  that  sound.  These  three  centres  thus  comprise 
the  sensory  branch  of  speech. 

The  motor  branch  comprises  the  ordinary  centres  in  the 
precentral  region  for  the  articulatory  muscles  and  their 
connections  with  their  corresponding  lower  motor  neurons, 
and  also  higher  centres  situated  m  the  intermediate  pre- 
central area,  which  are  psycho-motor  centres  for  spoken  and 
A^Titten  language. 

The  precise  localisation  in  the  left  cerebral  hemisphere  of 
the  various  centres  concerned  in  speech  may  be  summarised 
as  follows  : — 

(a)  Sejisory  : — - 

(i.)  Visual  Word  Centre,  in  the  angular  and  supra- 
marginal  gyri. 

(ii.)  Auditory  Word  Centre,  in  the  posterior  part  of  the 
first  temporal  gyrus. 

(iii.)  Centre  for  Sense  of  Articulatory  Muscle  movement 
in  the  post-central  gyrus  fairly  close  to  the  Sylvian 
fissure. 

[b)  Motor  •— 

(i.)  Primary  motor  centres  for  tongue,  lips,  larynx, 
hand,  fingers,  etc.,  in  the  precentral  gyrus. 

(ii.)  Higher  centre  for  spoken  words  (Broca's  area) 
towards  the  base  of  the  third  frontal  convolution. 


DISEASES   OF  THE    BRAIN  531 

(iii.)  Higher  centre  for  Amting  in  the  posterior  part  of 

the  second  frontal  convolution. 

The  bulk  of  these  centres  (especially  the  sensory  ones) 
lie  in  close  relation  to  the  Sylvian  fissure,  so  that  a  throm- 
botic lesion  of  the  Sylvian  artery  is  certain  to  cause  extensive 
aphasia,  though  the  actual  muscles  concerned  in  speech  are 
not  afifected. 

Aphasia  can  be  divided  into  two  groups,  first,  Sensor}^  and 
secondly  Motor,  though  a  mixed  aphasia  may  quite  well  occur. 

A.  Sensory  aphasia  may  be  found  in  lesions  of  either  the 
visual  or  auditory  word  centres  or  in  lesions  involving  the 
commissural  fibres  connecting  these  centres  with  each  other 
or  with  the  other  speech  centres. 

Lesions  of  the  Visual  Word  Centre  cause  word  blindness, 
with  inability  to  read,  to  write  to  dictation,  or  to  copy 
printed  or  written  words. 

Nearly  always,  in  addition,  there  is  some  difficulty  in 
writing  spontaneously,  though  this  can  often  be  accomplished 
without  more  serious  error  than  the  occasional  use  of  A\Tong 
words. 

If  the  path  from  the  visual  to  the  auditory  word  centre 
is  interrupted,  the  patient  is  unable  to  read  aloud  unless  he 
is  a  very  strong  visual  and  has  a  well-developed  connection 
from  the  visual  word  centre  to  Broca's  centre. 

The  connections  from  the  visual  word  centre  to  the  pre- 
central  and  intermediate  precentral  motor  speech  centres 
are  concerned  respectively  with  copying  and  transferring 
printed  to  written  language. 

Lesions  of  the  Auditory  Word  Centre  cause  word  deafness — 
that  is  to  say,  inability  to  understand  what  is  said  though 
being  able  to  hear  quite  well.  A  secondary  result  of  word 
deafness  is  to  produce  unintelligible  speech,  not  because  there 
is  any  real  motor  aphasia,  but  because  there  is  no  store- 
house of  words  to  draw  upon  ;  the  result  is  a  medley  of 
incomprehensible  sounds  which  seems  to  the  patient  to  be 
ordinary  speech. 

When  the  auditory  word  centre  itself  is  intact,  lesions 
of  the  commissural  fibres  connecting  this  centre  with  the 
other  centres  may  produce  aphasic  symptoms  as  follows  : — 

Lesions  of  the  path  from  the  auditory  word  centre  : — - 

34—2 


532  MEDICAL   DIAGNOSIS 

(i.)  To  the  chief   visual   centre   in   the   occipital   lobe 

causes  inability  to  pick  out  named  objects. 

(ii.)  To  the  visual  ivord  centre  causes  inability  to  pick 

out  words  named  from  a  sheet  of  print  or  writmg ;    at  the 

same  time  the  patient  can  read  aloud. 

(iii.)  To  the  precentral  motor  areas  causes  inability  to 

repeat  spoken  words. 

(iv.)  To  Broca's  area  causes  complete  inability  to  carry 

on  conversation,  because,  although  the  patient  can  under- 
stand what  is  said  to  him,  the  responsive  impulses  aroused 

in  the  auditory  word  centre  are  cut  off  from  the  higher 

centre  for  their  spoken  expression. 

In  V\k.e  manner  interference  with  the  path  to  the  higher 

centre    for    wTitmg     (cheiro-kinsesthetic    centre)    causes 

inability  to  write  to  dictation. 

B.  Motor  Aphasia.  In  complete  motor  aphasia  there  is 
inability  to  speak  or  write,  although  the  patient  can  under- 
stand what  is  said  to  him  and  can  read. 

(i.)  Lesions  in  Broca's  area  cause  inability  to  speak  words, 

though  there  is  no  paralysis  of  the  articulatory  muscles, 
(ii.)  Lesions  in  the  posterior  part  of  the  second  frontal 

convolution  cause  inability  to  write  spontaneously.     Copy- 

ng  may  stiU  be  possible, 
(iii.)  Lesions    in    the    primary    motor    centres    of    the 

precentral  gyrus  cause  a  dysarthria  from  simple  paralysis 

of  the  articulatory  muscles. 

When  the  speech  centres  are  destroyed  by  a  lesion  of  the 
left  cerebral  hemisphere  before  the  age  of  three  years  there 
is  a  good  prospect  of  developing,  by  education,  similar 
compensatory  centres  m  the  right  half  of  the  brain. 

After  the  age  of  three  years  this  does  not  often  occur. 

VII.  Apraxia.  By  this  is  meant  the  inability  to  use, 
properly,  certain  objects  the  name  and  use  of  which  are 
perfectly  understood  by  a  patient  who  shows  no  signs  of 
motor,  sensory,  or  mental  impairment.  Apraxia  is  most 
evident  in  the  case  of  objects  which  require  considerable 
co-ordination  of  small  muscles  and  muscle  groups  for  their 
proper  use,  for  example  playing  the  violin  or  type-setting. 
Apraxia  has  been  noted  in  lesions  of  the  Corpus  Callosum  and 
also,  more  rarely,  of  the  frontal  lobes. 


CHAPTER  VI 

DISEASES  OF  THE  SPINAL  CORD 

I.  Hsematomyelia  (Spiiial  Apoplexy).  As  a  primary 
condition  haemorrhage  into  the  spinal  cord  is  nearl}-  always 
traumatic.  Secondary  haemorrhage  may  take  place  into  a 
syi'ingo-myelic  cavity,  into  a  myelitic  area,  or  into  a  new 
growth. 

The  onset  is  sudden,  and  the  signs  become  fully  established 
within  a  few  hours.  There  are  neither  convulsions  nor  u^icon- 
sciousness. 

The  first  sign  is  pain  referred  to  the  root  areas  which  corre- 
spond to  the  lesion  ;  this  may  pass  off  in  a  few  days. 

Within  a  few  hours  (often  a  few  minutes)  there  is  complete 
sensory  and  motor  paralysis  (flaccid)  below  the  level  of  the 
lesion.  As  time  goes  on  the  motor  paralysis  assumes  the 
spastic  form  associated  with  p}Tamidal  tract  lesions,  and 
tactUe  sensation,  together  with  some  sense  of  passive 
position,  tends  to  return.  Trophic  changes  are  trouble- 
some, particularly  when  the  haemorrhage  is  in  the  lumbar 
enlargement. 

At  the  level  of  the  lesion  there  is  permanent  flaccid 
paralysis  from  anterior  horn  destruction.  This  results  in 
contracture  deformities,  which  are  especially  well  shown  in 
the  hands  when,  as  is  most  often  the  case,  the  haemorrhage 
is  in  the  cervical  enlargement. 

All  cases  are  not  so  extreme  as  implied  in  the  above  descrip- 
tion ;  sometimes  only  half  the  cord  is  affected,  and  in  such 
cases  Brown-Sequard's  type  of  paralysis  may  be  expected. 

The  chief  difficulties  in  diagnosis  may  ari.se  in  cases  of: — • 

(i.)  Acute  Myelitis.  Here  there  is  a  more  gradual  onset, 
with  some  preliminary  constitutional  disturbance  and  no 
history  of  trauma. 

(ii.)  Acute  Poliomyelitis.  Here  there  is  constitutional 
disturbance  at  the  outset  and  usually  a  limitation  of  the 


534  MEDICAL   DIAGNOSIS 

paralysis  to  the  motor  system  ;    further,  the  symptoms  are 
not  usually  localised  to  a  definite  segmental  level. 

II.  Syringo-myelia.  By  syringo-myelia  is  usually  meant 
the  development  of  cavities  in  the  spinal  cord  as  the  result 
of  degeneration  in  a  diffuse  gliosis  of  the  grey  matter  of  the 
cord. 

It  is  a  disease  of  young  people  (10  to  30  years),  and  in  a 
considerable  proportion  of  cases  there  is  evidence  of  spina 
bifida  to  a  greater  or  less  extent. 

Cystic  degeneration  may  also  occur  m  gliomas  or  sarcomas 
of  the  spinal  cord  ;  in  these  cases  there  are  the  signs  of  intra- 
medullary tumour  before  those  of  syringo-myelia  develop. 
The  principal  seat  of  the  gliosis  is  found  in  the  great 
majority  of  cases  to  be  the  cervico-dorsal  region  of  the  cord, 
and  the  characteristic  signs  are  to  be  looked  for  in  the 
arms  and  chest.  If,  however,  the  growth  spreads  upwards 
bulbar  symptoms  are  likely. 

The  diagnosis  rests  upon  the  following  features  : — 
(i.)  At  the  level  of  the  lesion  : 

(a)  Bilateral  impairment  or  loss  of  the  sensations  of 
heat  and  cold  and  pain  (not  necessarily  strictly  segmental), 
with  preservation  of  tactile  sensibility.  In  very  late 
cases  all  forms  of  sensation  may  be  abolished. 

(6)  Bilateral  atrophic  paralysis  of  various  muscles  or 
muscle  groups,  the  weakness  being  often  in  excess  of  the 
atrophy.  This  paralysis  has  no  constant  distribution  or 
order  of  development,  but  is  most  often  seen  in  the  small 
muscles  of  the  hands,  the  ulnar  border  of  the  forearms, 
and  the  shoulders.  There  may  be  no  muscular  atrophy 
even  at  a  late  stage  of  the  disease. 

(c)  Trophic  and  vaso-motor  changes.  There  is  often 
passive  hypersemia  with  a  partial  sweat  secretion.  This 
oedematous  condition  produces  the  "  main  esculente  "  or 
succulent  hand,  which  is  of  considerable  diagnostic  import- 
ance. 

In  other  cases  painless  whitlows  appear,  and  may  pro- 
duce a  most  extensive  cellulitis  of  the  hand  and  forearm 
(Morvan's  disease).  Perforating  ulcers,  arthropathies 
similar  to  Charcot's  joints,  and  spontaneous  fractures 
are  other  common  trophic  changes. 


DISEASES   OF   THE   SPINAL   CORD  535 

Dorsal  scoliosis  from  weakness  of  the  spinal  muscles 

is  nearly  always  present  at  some  stage  of  the  disease. 

(ii.)  Below  the  Lesion.  There  is  slowly  developing 
spastic  paralysis,  often  with  progressive  loss  of  sensation. 
Some  grade  of  spastic  paraplegia  from  pressure  on  the 
pjTamidal  tracts  can  nearly  alwaj'S  be  detected,  though, 
unless  the  lumbar  enlargement  is  affected,  there  is  rarely 
any  sphincter  trouble. 

In  many  cases  the  earliest  symptoms  of  all  are  subjective 
sensations  of  heat  and  cold  in  the  arms,  which  precede 
the  objective  changes  for  a  short  time. 

It  must  be  remembered  that  different  cases  vary  very 
much  in  the  exact  nature  and  distribution  of  their  dis- 
sociated anaesthesiae  ;  for  example,  there  may  be  no  loss  of 
pain  sensibilit}^  or  if  present  it  may  not  coincide  in  distri- 
bution v.ith  the  area  of  thermal  changes.  Again,  thetlistal 
changes  which  result  from  the  interruption  of  afferent  and 
efferent  tracts  is  commonly  much  more  marked  on  one  side 
of  the  body  than  the  other,  owing  to  the  asymmetry  of 
the  new  tissue  formation  in  the  cord. 

There  is  usually  no  difficulty  in  diagnosing  a  case  of 
syringo-myelia,  since  there  is  no  other  condition  which  causes 
the  same  symptoms  extending  over  so  long  a  period  of  time. 

Cervical  rib  is  unilateral  and  causes  no  cord  symptoms, 
while  the  sensory  loss  is  of  the  peripheral  type. 

IntrameduUarij  tumour  may  closely  resemble  syringo- 
myelia, but  the  symptoms  are  largely  unilateral  for  some 
time,  and  unilateral  spastic  phenomena  below  the  lesion, 
with  extensor  plantar  response  and  sphincter  disturbance, 
are  much  more  prominent. 

III.  Acute  Myelitis.  This  is  a  rare  condition  and  signifies 
an  inflajHinatoiy  affection  of  the  actual  tissues  of  the  cord, 
the  result  of  a  definitely  infective  process,  though  not  due 
to  anyone  specific  infection  :  for  example,  it  may  occur  pri- 
marily following  a  chill  or  for  no  known  cause,  or  it  may  be 
secondary  to  such  infections  as  small-pox,  influenza,  enteric 
fever,  or  gonorrhoea.  An  interesting  form  of  myelitis  is 
that  which  sometimes  develops  during  the  course  of  a 
severe  cystitis.  The  term  "  Myelitis  "  is  not  con.spicuously 
accurate,  for  it   is  evident    that    the   meninges  are  nearly 


536  MEDICAL  DIAGNOSIS 

always  involved  also  in  view  of  the  extreme  frequency  of 
pain  as  an  early  symptom. 

The  most  common  condition  to  which  the  name  myelitis 
is  applied  is  the  result  of  thrombosis  in  the  spinal  arteries 
secondary  to  syphilitic  endarteritis  ;  this  condition  is 
described  in  the  section  dealing  with  syphilis  of  the  central 
nervous  system. 

Acute  myelitis  occurs  in  two  main  forms — the  focal 
type,  or  Acute  Transverse  Myelitis,  and  the  disseminated 
type,  or  Acute  Ascending  Myelitis. 

It  sometimes  happens  that  the  infection  is  so  acute  that 
it  proceeds  to  abscess  formation  withm  the  cord, 

(i.)  Acute  Transverse  Myelitis.  There  are  the  general 
symptoms  of  an  infective  disorder,  fever,  malaise,  and  pain 
in  the  back,  which  merge  rapidly  (that  is  to  say  in  a  few 
hours)  into  the  clinical  picture  of  myelitis. 

The  earliest  special  symptoms  are  subjective  sensory 
symptoms,  pain  at  the  level  of  the  lesion,  and  numbness  and 
tingling  of  the  feet  and  legs. 

These  sensations  are  replaced  by  a  rapidly  progressive 
loss  of  sensation  and  muscle  power  below  the  lesion,  with 
complete  loss  of  sphincter  control.  The  motor  paralysis 
is  of  the  completely  flaccid  type  with  absence  of  all  reflexes. 
Bed-sores  and  trophic  changes  are  particularly  troublesome. 

The  sensory  and  motor  changes  in  the  limbs  usually 
proceed  hand  in  hand,  but  sometimes  one  may  be  obviously 
in  advance  of  the  other.  Cramp-like  pains  in  the  legs  are 
by  no  means  uncommon  while  the  paralysis  is  developing. 

The  inflammatory  process  usually  involves  two  or  three 
spinal  segments  about  the  level  of  the  9th  dorsal  vertebra, 
and  at  the  upper  level  of  the  lesion  there  may  be  persistent 
hypersesthesia  and  constricting  girdle  pains. 

If  the  lesion  does  not  affect  the  entire  thickness  of  the 
cord  the  paratysis  of  the  limbs  tends  to  be  spastic  and  the 
plantar  response  extensor. 

In  the  few  cases  in  which  the  patient  survives  a  complete 
acute  transverse  myelitis,  a  typical  spastic  paraplegia 
develops,  with  a  notable  tendency  for  the  development  of 
contractures  of  the  adductor  and  flexor  muscles. 

(ii.)  Acute  Ascending  Myelitis.     The  onset  and  symptoms 


DISEASES   OF   THE   SPINAL   CORD  537 

are  the  same  as  in  acute  transverse  mj^elitis,  but  the  disease 
does  not  remain  limited  to  a  definite  level  in  the  cord  and 
can  be  observed  to  progress  segment  by  segment  higher  up 
the  cord. 

The  great  majority  of  these  cases  end  fataUy  by  extension 
upwards  of  the  inflammation  to  the  bulb.  Occasionally 
the  upward  spread  appears  to  stop  suddenly,  and  in  such 
cases  a  fair  recovery  may  be  made. 

Buzzard  considers  that  the  essential  lesion  in  these  cases 
is  a  spinal  lymphangitis. 

Post  mortem  the  inflammatory  areas  may  be  focal  and 
disseminated  or  diffuse  and  continuous.  Clinically  it  has 
been  noted  that  the  progress  is  not  always  steadily  up  the 
cord  segment  by  segment,  but  that  occasionally  several 
segments  are  skipped. 

IV.  Tumours  of  the  Spinal  Cord.  (Intra -meduflary 
Tumours.)  Sarcomas,  gliomas,  tuberculomas,  and  gummas 
may  be  found  in  the  spinal  cord.  Gummas  do  not  arise  in 
the  actual  tissues  of  the  cord,  but  in  the  membranes  or  around 
the  blood  vessels. 

The  symptoms  of  an  intra-meduUary  tumour  naturally 
vary  with  the  position  of  the  tumour,  but,  speaking  generally, 
are  as  follows  : — 

(i.)  Segmental  sensory  dissociation,  as  in  syringo-myelia. 
(ii.)  Unilateral  cord    symptoms,    often  of  the  Brown- 
Sequard  tj^^e. 

(iii.)  Atrophic  muscular  paralysis  of  segmental  distribu- 
tion, with  atrophy  in  excess  of  weakness  (c/.,  syringo- 
myelia, in  which  the  converse  obtains). 

(iv.)  Early  sphincter  trouble  and  extensor  plantar 
response. 

As  the  disease  progresses  bilateral  spastic  paraplegia 
develops,  with  progressive  sensory  loss  below  the  level  of  the 
tumour. 

The  resemblance  of  intra -medullary  tumour  to  syringo- 
myelia is  striking  but  its  duration  is  very  much  less,  being 
rarely  more  than  two  to  three  years.  The  persistence  of 
unilateral  cord  symptoms  for  a  considerable  time  is  an  impor- 
tant differential  point.  The  trophic  changes  ami  scoliosis 
of  syringo-myelia  should  also  be  remembered. 


538  MEDICAL  DIAGNOSIS 

V.  Diver's  Paralysis  (Caisson  Disease).  This  is  the  result 
of  a  too  rapid  return  to  the  normal  atmospheric  pressure 
after  exposure  to  a  markedly  increased  pressure  as  in  a 
diving-bell.  While  in  the  diving-bell  the  diver's  blood 
becomes  super-saturated  with  gases  by  reason  of  the  extra 
pressure,  and  bubbles  of  gas  (probably  nitrogen)  escape 
from  the  capillaries  into  the  spinal  cord  if  the  diver  is  not 
permitted  to  return  to  normal  pressure  very  gradually. 

The  effect  of  free  gas  in  the  spinal  cord  is  to  destroy  the 
nervous  tissues,  and  the  symptoms  vary  with  the  amount 
of  gas  that  is  liberated.  The  principal  changes  are  usually 
in  the  dorsal  region. 

In  severe  cases  there  are  the  signs  and  sj^mptoms  of  a  com- 
plete transverse  lesion  of  the  cord. 

In  less  severe  cases  there  are  numbness  and  tingling  of  the 
extremities,  severe  pains  in  the  joints,  sometimes  girdle 
pains  and  vomiting,  motor  weakness  in  the  legs,  and  some- 
times diffuse  blunting  of  sensation. 

Headache,  giddiness,  and  deafness  are  commonly  com- 
plained of  in  addition  to  the  more  special  spinal  symptoms. 

VI.  Compression  of  the  Spinal  Cord.  The  spinal  cord  may 
be  compressed  by  fractures  or  dislocations  of  the  vertebral 
column  by  new  growth  or  tuberculous  caries  of  the 
vertebrae  or  by  new  growth  of  the  membranes. 

The  symptoms  of  compression  of  the  cord  fall  into  three 
groups,  the  prominence  of  each  group  varying  with  the 
nature  of  the  primary  lesion  : — - 

(i.)  Symptoms  due  to  disturbance  of  Nerve  Roots.  A 
common  symptom  is  intense  pain  over  the  area  supplied 
by  the  damaged  root.  Cutaneous  hypersesthesia  may  be 
present  as  well,  but  sometimes  this  gives  way  to  tactile 
ansesthesia,  even  though  the  pains  persist. 

If  the  anterior  nerve  roots  are  involved  there  is  weakness 
and  wasting  of  muscles  supplied  by  these  roots  ;  the 
anterior  root  symptoms  are,  however,  often  unobtrusive. 
Pain,  though  a  constant  symptom,  is  in  many  cases  not 
referred  to  the  areas  typical  of  nerve  root  distribution  ;  it 
often  resembles  rheumatic  pains  in  the  neighbourhood,  or 
it  may  be  localised  to  the  spine,  to  a  joint,  or  to  the  breast. 

(ii.)  Cord    Symptoms.       Progressive     paraplegia,     most 


DISEASES   OF   THE   SPINAL  CORD  539 

marked  at  first  on  the  side  of  the  root  symptoms,  with 
sphincter  disturbance  and  gradual  loss  of  sensation  below 
the  lesion  as  the  pressure  increases. 

The  paralysis  is  spastic  in  type  and  the  plantar  reflex  is 
extensor,  but  if  the  cord  becomes  completely  destroj^ed 
physiologically  the  paralysis  becomes  flaccid. 

(iii.)  Signs  of  Local  Bone  Disease.  Spinal  curvatures  and 
angular  deformities  are  common  in  tuberculous  disease. 
A  tumour  of  the  vertebrae  may  be  palpable. 

Local  tenderness  on  percussion  or  manipulation,  stiffness, 
and  limitation  of  movement  are  very  constant  phenomena 
in  caries,  while  severe  local  pain,  much  increased  by  move- 
ment, is  often  found  in  vertebral  new  growth. 

As  would  be  expected,  these  signs  of  local  bone  disease 
are  rarely  found  in  meningeal  tumours  unless  the  upper 
cervical  region  is  involved.  ' 

It  is  worthy  of  note  that  in  cases  of  paraplegia  due  to 
compression  from  tuberculous  disease  of  the  spine  subjective 
root  symptoms  are  often  conspicuously  absent. 

The  differential  diagnosis  between  extra-thecal  and  intra- 
thecal spinal  meningeal  tumours  is  usually  impossible,  but 
it  maybe  stated  that,  as  a  rule,  an  intra-thecal  tumour  causes 
early  root  symptoms  and  early  compression,  which  for  a 
time  is  to  some  extent  unilateral,  while  with  extra-thecal 
tumours  compression  is  of  slower  onset,  and  when  it  does 
occur  is  not  so  likely  to  give  unilateral  signs. 

Meningeal  tumours  must  be  differentiated  from — 

(a)  Aortic  Aneurysm  by  the  physical  signs  of  this  disease 

and  by  the  X-rays. 

(6)  Intra-medullary  Tiinwiirs  by  the  early  dissociation 

of  tactile  and  thermal  scnsibilit}',  by  the  absence  of  root 

pains,  and  by  the  more  conspicuous  muscular  atrophy. 
(c)   Tuherailous   Disease  of  the  Spine  by  the  rigidity, 

impaired  mobility  or  deformity  of  the  spine,  by  the  local 

tenderness  of  the  spine  to  percussion,  by  the  excess  of 

motor    over    sensory    symptoms,    by    the    tendency    to 

abscess  formation,  and  by  the  younger  age  of  the  patient 

and  possible  evidence  of  tuberculous  disease  elsewhere. 
(fl)  Malignant  Disease  of  the  Vertehrrr  by  the  possible^ 

history  of  a  previous  operation  for  carcinoma,  since  verte- 


540  MEDICAL   DIAGNOSIS 

bral  growths  are  usually  secondary,  by  the  extreme  local 
pain  and  tenderness  on  manipulation,  by  the  severity  of 
the  root  pains,  which  are  often  increased  by  movement, 
and  possibly  by  the  presence  of  palpable  nodules  of 
growth.  The  remission  of  the  pain  with  absolute  rest  is 
striking  feature  of  many  of  these  cases. 


CHAPTER   VII 

SYPHILITIC  DISEASES  OF  THE  NERVOUS 
SYSTEM 

The  frequency  with  which  hemiplegia  and  kindred 
conditions  may  result  from  thrombosis  of  the  cerebral 
arteries  due  to  syphilitic  endarteritis  has  aheady  been 
discussed,  but,  apart  from  this,  syphilis  is  the  cause  of  several 
other  definite  clinical  nervous  diseases  which  will  now  be 
considered  separately  under  the  following  headings  : — •  ^ 

I.  Cerebro-spinal  Sj^hilis  (excluding  Hypertrophic  Pachy- 
meningitis and  Meningo-myelitis). 

II.  Syphilitic  Spinal  Pachymeningitis  (Hjrpertrophic 
Pachymeningitis). 

III.  Syphilitic  Meningo-mj'-elitis. 

IV.  Tabes  Dorsalis  (Locomotor  Ataxy). 

V.  General  Paralysis  of  the  Insane  (Progressive  Paralytic 
Dementia). 

I.    CEREBRO-SPINAL  SYPHILIS. 

The  essential  lesion  is  gummatous  formation. 

(a)  Localised  Cerebro-spinal  Syphilis.  A  single  gumma  is 
rare,  but  may  cause  symptoms  of  tumour  either  of  the  brain 
or  spinal  meninges. 

Lepto-meningitis  in  the  skull  may  cause  severe  headache 
and,  if  situated  over  the  motor  cortex,  Jacksonian  con- 
vulsions or  even  muscular  paralysis, 

Lepto-meningitis  in  the  cord  is  generally  associated  with, 
and  indeed  may  cause,  local  myelitis  ;  occasionally  it  may 
simulate  an  intra-thecal  tumour  and  cause  compression 
paraplegia  by  damming  up  the  cerebro-spinal  fluid. 

Pachymeningitis  in  the  skull  is  seldom  strictly  localised  ; 
more  often  it  is  diffused  over  the  base  of  the  brain.     In 


542  MEDICAL   DIAGNOSIS 

the  spinal  cord  it  is  commonly  localised  to  the  cervical  and 
lumbar  enlargements  {vide  infra). 

(6)  Diffuse  Cerebro-spinal  Syphilis.  This  results  from  a 
more  or  less  diffuse  gummatous  infiltration  of  the  membranes; 
the  affection  is  often  limited  to  the  membranes  within  the 
skull,  but  signs  of  spinal  meningitis  may  be  present  also. 

The  most  striking  and  important  signs  are  paralysis  of 
one  or  more  of  the  cranial  nerves  :  the  third  and  sixth 
nerves  are  specially  picked  out ;  unequal,  irregular  pupils 
with  imperfect  reaction  to  light  are  nearly  always  present. 

Convulsive  attacks,  often  of  Jacksonian  type,  are  common, 
as  are  the  more  general  signs  of  gross  intra -cranial  disease, 
headache,  vomiting,  mental  impairment,  and  even  optic 
neuritis. 

The  resemblance  to  general  paralysis  of  the  insane  is 
often  striking,  but  the  peculiar  mental  change  is  lacking,  as 
is  the  tremor  and  the  slurring  speech.  Further,  cranial 
nerve  paralyses  are  evident  much  earlier  and  the  cerebro- 
spinal fluid  gives  a  negative  Wassermann  reaction  in  the 
majority  of  cases. 

II.     SPINAL    PACHYMENINGITIS    (HYPERTRO- 
PHIC PACHYMENINGITIS). 

This  is  usually  limited  to  the  cervical  and  lumbar 
enlargement,  often  to  the  former  alone. 

The  earliest  symptoms  are  sensory,  and  consist  of  pain 
in  the  back  of  the  neck  or  lumbar  region,  worse  on  movement, 
and  root  pains  owing  to  the  involvement  of  the  issuing 
posterior  nerve  roots.  These  pains  at  first  are  most  marked 
on  one  side,  but  soon  become  bilateral.  Hypersesthesia 
is  usually  present,  and  in  advanced  cases  anaesthesia  may 
develop. 

After  a  varying  time,  sometimes  not  for  months,  atrophic 
paralyses  develop,  at  first  in  the  small  muscles  of  the  hands 
and  feet  and  in  the  flexor  groups.  A  characteristic  contrac- 
ture of  the  hands  often  develops  ;  the  wrist  and  fingers  are 
extended  and  the  interphalangeal  joints  are  flexed. 

In  severe  cases  signs  of  spastic  paraplegia  occur  from 
compression  of  the  cord. 


SYPHILITIC  DISEASES  OF  XERVOUS  SYSTEM     543 

There  is  a  lymphocytosis  in  the  cerebro-spinal  fluid  in 
this  as  in  all  syphilitic  affections  of  the  central-nervous 
system. 

III.    SYPHILITIC    MENINGO-MYELITIS. 

Although  there  is  always  some  co -existing  spinal  lepto- 
meningitis, the  essential  cause  of  this  condition  is  myelitic 
softening,  the  result  of  thrombosis  in  the  spinal  arteries. 
The  lower  dorsal  region  is  most  often  attacked. 

There  are  nearly  always  preliminary  subjective  sensory 
symptoms,  such  as  numbness  and  tingling  in  the  feet  and 
legs  ;  these,  hoMever,  may  be  very  slight,  and  the  fact  that 
they  are  present  may  only  be  ascertained  by  careful  question- 
ing. The  striking  feature  of  these  cases  is  the  onset  of  para- 
plegia, which  usually  develops  quite  suddenly.  ' 

In  the  great  majority  of  cases  the  paralysis  is  spastic  in 
type,  the  deep  reflexes  are  increased,  and  the  plantar 
reflex  is  extensor.  If  the  lesion  is  so  extensive  as  to  amount 
to  a  complete  transverse  lesion,  the  paralysis  is  utterly 
flaccid,  but  this  is  rare. 

At  the  level  of  the  lesion  there  is  a  band  of  hypersesthesia, 
and  all  forms  of  sensation  are  impaired  or  lost  below  this. 
The  sharp  limitmg  line  between  normal  and  disturbed 
sensation  is  rather  characteristic. 

Sphmcter  trouble  (retention  of  urme  and  incontinence  of 
faeces)  develops  with  the  paraplegia.  Bedsores  are  likely  to 
appear  and  in  the  more  extensive  lesions  may  prove  very 
troublesome.  The  prognosis  is  faiily  good,  but  as  recovery 
takes  place  muscular  spasms  are  often  unpleasantly  promi- 
nent. 

Syphilitic  Meningomyelitis  can  be  distinguished  from — 
(i.)  Acute  Transverse  Myelitis  by  the  absence  of  con- 
stitutional disturbance,  the  probability  of  the  paralysis 
being  spastic  from  the  commencement,  and  the  relative 
absence  of  pain. 

(ii.)  Disseminated  Sclerosis  by  the  absence  of  nystag- 
mus, altered  speech  and  intentional  tremor,  and  the 
presence  of  sensory  changes. 

(iii.)  Subacute  Combined  Degeneration  by  the  character 


544  MEDICAL  DIAGNOSIS 

and  distribution  of  the  sensory  changes  and  by  the  blood 

picture  {vide  p.  556). 

Lastly,  as  in  all  forms  of  cerebro-spinal  syphilis,  the  charac- 
teristic eccentric,  unequal,  sluggish  pupils  may  be  found. 
The  Wassermann  reaction  to  the  blood  and  cerebro-spinal 
fluid  is  not  as  mformative  as  might  be  expected,  since  a 
considerable  proportion  of  presumably  syphilitic  cases  give 
negative  reactions  to  both.  There  is,  however,  a  considerably 
higher  percentage  of  positive  reactions  to  the  blood  in 
meningo -myelitis  than  in  ordinary  cerebral  syphilis, 

IV.    TABES  DORSALIS. 

The  essential  change  in  this  disease  is  a  progressive 
degeneration  of  the  sensory  fibres  as  they  enter  the  cord 
through  the  posterior  nerve  roots  and  as  they  travel  up  the 
cord. 

The  disease  starts  in  the  lumbo-sacral  region  as  a  rule, 
but  the  cervical  region  is  commonly  affected  also,  as  well  as 
the  intervening  dorsal  region. 

The  degeneration  is  most  marked  in  the  posterior  columns 
of  the  cord.  The  posterior  root  ganglia  escape,  as  do  the 
nerve  roots  outside  the  cord.  The  anterior  columns  are 
affected  to  a  certain  extent  in  a  small  proportion  of  cases. 

The  manner  in  which  syphilis  produces  this  characteristic 
lesion  is  not  yet  understood  ;  men  are  much  more  frequently 
affected  than  women  (10  :  1),  and  the  common  age  incidence 
is  30  to  40  years. 

The  clinical  manifestations  of  tabes  dorsalis  are  very 
numerous  ;  no  single  one  is  absolutely  indispensable,  and 
as  their  order  of  development  is  not  altogether  characteristic 
they  are  best  considered  independently. 

(i.)  The  Cranial  Nerves.  Temporary  or  permanent,  partial 
or  complete,  ophthalmoplegia  is  sometunes  present. 

Laryngeal  paralyses  (abductor)  are  common,  as  is 
anaesthesia  of  the  palate. 

By  far  the  most  important  cranial  nerve  sign  is  connected 
with  the  pupil.  As  in  general  paralysis  and  cerebro-spinal 
syphUis,  the  pupils  often  show  irregularity  of  outline  and 
inequality.     In  addition  there  is  impairment  or  loss  of  the 


SYPHILITIC  DISEASES  OF  NERVOUS  SYSTEM     545 

light  reflex,  while  the  power  of  contracting  to  accommoda- 
tion is  preserved  (the  Argyll-Robertson  reaction).  This 
phenomenon  is  present  in  about  70  per  cent,  of  all  cases  of 
tabes.  It  is  to  be  noted  that  the  consensual  light  reflex 
may  be  present  when  the  direct  reflex  is  gone. 

The  essential  point  is  a  sluggish  (not  necessarilj-  absent) 
contraction  to  light  in  a  pupil  of  irregular  outline,  provided 
that  the  irregularity  is  not  due  to  old  iritis.  The  eyes 
must  be  tested  separately,  and  a  good  light  must  be  used. 
Primary  optic  atrophy  occurs  in  10  per  cent,  of  all  cases 
of  tabes. 

(ii.)  Motor  System.  I'me  wasting  from  anterior  horn-coll 
degeneration  occurs  in  a  small  proportion  of  cases. 

Hypotonus  of  the  nmscles  is  a  conspicuous  feature  of 
most  cases.  The  ligaments  are  affected  as  well,  and  hyjoer- 
extension  of  the  limbs  with  general  increased  arthritic 
mobility  can  nearly  always  be  demonstrated. 

Ataxy  may  develop  early  or  late  ;  the  muscular  inco- 
ordination is  the  result  of  the  loss  of  sense  of  position  of 
the  muscles  and  joints.  At  first  this  is  compensated  for 
by  increased  visual  activity  (the  patient  looks  where  his 
limbs  are),  and  therefore  is  most  noticed  in  the  dark. 

Ataxy  is  shown  by  inability  to  walk  along  a  straight  line  ; 
a  stamping,  unsteady,  exaggerated  gait,  in  which  the  legs 
arc  kept  wide  apart  and  the  feet  raised  too  high  ;  inability 
to  stand  with  the  feet  together  and  the  eyes  shut  (Rom- 
berg's sign),  and  inability  to  perform  the  finer  movements 
which  require  most  muscular  co-ordination,  such  as  writing, 
threading  needles,  fastening  buttons,  etc. 

(iii.)  Sensory  System.  (a)  Subjective.  ''Lightning''' 
pains  of  ])ar().\ysmal  nature  shooting  down  the  arms  and 
legs  ;  these  appear  to  be  just  beneath  the  skin  and  may 
affect  the  joints  as  well  as  the  limbs. 

Deep  pains  referred  to  the  bones  or  nmscles,  which  are 
not  paroxysmal,  but  are  often  persistent  for  months. 

Girdle  pains  :  band-like  sensations  of  compression,  pain, 
heat,  and  numbness. 

{b)  Objective.     Loss  of   painful  pressure  sense,  loss  of 
sense  of  ])osition,  loss  or  blunting  of  cutaneous  pain,  and  to 
a  much   less  extent   of  tactile  sense,   most  evident  along 
M.D.  35 


546  MEDICAL   DIAGNOSIS 

the  ulnar  border  of  the  forearms,  the  thorax,  the  perinseum, 
and  the  legs  and  feet. 

(iv.)  Reflexes.  The  superficial  abdominal  reflexes  are 
preserved. 

The  Tendon  Reflexes  in  the  lower  Imibs  are  diminished 
at  first  and  eventually  lost. 

The  Tendon  Reflexes  of  the  arm  are  lost  if  the  cervical 
cord  is  affected. 

The  Organic  Reflexes.  There  is  often  a  frequent  and 
urgent  desire  to  pass  water,  but  when  the  patient  tries 
he  is  at  first  unable  and  then  soon  after  passes  it  in  a  hurry, 
often  involuntarily. 

The  Generative  Functions.  At  first  there  is  increased 
sexual  desire  and  capacity  ;  this  does  not  last  long  and  is 
followed  by  impotence  and  lack  of  all  desire. 

(v.)  Visceral  Crises.  (a)  Gastric  Crises  consist  of  attacks 
of  nausea,  vomiting,  and  severe  abdommal  pain,  which  may 
last  for  several  days. 

(6)  Laryngeal  Crises  consist  of  sudden  laryngeal  spasms, 
with  pam,  stridor  and  a  feeling  of  suffocation. 

(c)  Rectal,  vesical,  intestinal,  cardiac,  and  respiratory 
crises  are  also  described. 

(vi.)  Trophic  Changes,  {a)  Progressive  emaciation  is 
nearly  always  to  be  recognised. 

(6)  Charcot's  Joints.  Joint  changes  follow  relaxation 
of  the  ligaments  and  trifling  injuries.  The  pathological 
changes  closely  resemble  those  in  osteo-arthritis,  with  the 
addition  of  large  effusions  into  the  joints.  There  is  very 
increased  mobility  of  the  joints,  and  the  limb  may  become 
absolutely  flail-like.  Dislocations  may  occur.  There  is  no  pain. 

(c)  The  Tabetic  Foot.  Changes  in  the  tarsal  ligaments 
cause  the  arch  of  the  foot  to  drop  and  the  foot  to  become 
everted. 

(r?)  Perforating  Ulcers.  These  commence  as  a  corn, 
usually  at  the  base  of  the  great  toe  or  the  little  toe.  A 
painless  ulcer  next  forms  which  extends  deeply  into  the 
tissues  of  the  foot  and  eventually  exposes  the  bone.  Similar 
idcers  sometimes  occur  in  syringo-myelia  and  diabetes. 

(e)  Spontaneous  fractures  of  the  long  bones  are  sometimes 
found. 


SYPHILITIC  DISEASES  OF  NERVOUS  SYSTEM     547 

(vii.)  The  Cerebro-spinal  Fluid  contains  a  large  excess  of 
lymphocytes  (about  150  per  cubic  millimetre),  but  only  gives 
a  positive  Wassermann  reaction  in  60  per  cent,  of  aU  cases 
(vide  p.  511). 

The  diagnosis  of  tabes  clorsalis  does  not  commonly 
present  much  difficulty  provided  that  a  conscientious 
examination  of  the  entire  nervous  system  is  made. 

It  must  not  be  imagined  that  every  case  of  tabes  gives  all 
or  even  many  of  the  signs  just  described,  but  some  can 
practically  always  be  found  which  are  sufficiently  charac- 
teristic for  a  positive  diagnosis. 

The  most  constant  and  earliest  as  \^  ell  as  most  important 
signs  are  probably — 

(i.)  Impairment  of  light  reflex  (especially  in  an  eccen- 
tric pupil).  , 
(ii.)  Impairment  or  absence  of  knee-jerks, 
(iii.)  Loss  of  deep  muscle  sensibility  in  the  calves  of  the 

legs. 

(iv.)  Some  impairment  of  pain  sensibility,   especially 

in  the  ulnar  border  of  the  forearms. 

(v.)  Urgency  or  precipitancy  of  micturition. 

(vi.)  Romberg's  sign,  as  well  as  other  evidence  of  ataxy, 

is  very  significant  when  present,  but  may  not  develop  till 

late. 

Lightning  pains  must  not  be  mistaken  for  rheumatism 
or  neuritis.  The  "  neuralgic  "  symptoms  may  continue  for 
months  or  years  with  no  other  symptoms,  but  pui)il  changes 
are  nearly  always  present. 

Gastric  crises  have  before  now  led  to  laparotomy,  but 
other  signs  of  tabes  can  be  found  if  sought  for. 

There  are  some  grounds  for  believing  that  the  cases  in 
which  optic  atrophy  develops  early  may  remain  relatively 
free  from  ataxic  signs  for  long  ])eriods. 

Juvenile  Tabes  Dorsalis  develops  in  a  very  small  propor- 
tion of  cases  of  congenital  syphilis  or  of  syphilis  acquired  in 
infancy. 

The  disease  occurs  more  frequently  in  girls  than  boys  and 
starts  just  Ix'fore  ])nber(y.  TIk'  clinical  manifestulions  are 
the  same  as  in  the  a(hiit  form,  ^\itll  the  exception  that  optic 
atrophy  is  of  much  more  common  occurrence. 

35—2 


548  MEDICAL   DIAGNOSIS 

Congenital  tabes  may  at  first  be  mistaken  for  Fried- 
reich's disease,  but  in  this  there  are  no  pupil  changes  and 
there  are  nystagmus,  scoliosis,  club-foot,  and  an  extensor 
plantar  response  {vide  also  p.  563). 

V.  GENERAL  PARALYSIS  OF  THE  INSANE 

(Progressive  Paralytic  Dementia). 

As  tabes  dorsalis  is  to  the  spinal  cord  so  is  general 
paralysis  to  the  brain- — that  is  to  say,  there  is  a  progres- 
sive degeneration  of  the  cortical  cells  and  neurons,  the 
result  of  syphilis,  though  often  not  developing  for  many 
years  after  the  luetic  infection. 

The  spirochaete  of  syphilis  has  been  demonstrated  in  the 
cortex  of  the  brain,  and  practically  all  (over  95  per  cent.)  of 
these  cases  give  a  positive  Wassermann  reaction  to  both 
blood  serum  and  cerebro-spinal  fluid. 

The  association  in  the  same  patient  of  general  paralysis 
v/ith  tabes  dorsalis  is  by  no  means  infrequent  (tabo- 
paralysis). 

Men  are  affected  considerably  more  often  than  women;  the 
age  incidence  is  that  of  tabes  (35  to  50  years). 

Microscopically  there  is  degeneration  of  the  cortical 
tissues,  of  the  basal  ganglia,  and  also  of  the  pons, 
medulla  and  cord.  The  arterioles  are  thickened,  and  often 
there  is  a  perivascular  infiltratioti  of  small  round  cells. 

The  cerebro-spinal  fluid  contains  an  excess  of  lymphocytes. 

The  symptoms  are  best  considered  under  the  headings  of 
the  various  systems  : — 

(i.)  Mental.     These    are    usually    the    first    to    appear, 

and  consist  in  an  alteration  of  the    pre-existing  mental 

habit,  which  is  most  striking  when  a  person  of  orderly 

behaviour  becomes    guilty    of    gross    immorality,  petty 

thieving,  or  the  like. 

Very  striking  and  often  early  to  appear  are  inability  to 

concentrate  the  attention,   a  condition  of  exaltation,   a 

sense  of  self-satisfaction,  and  a  ridiculous  desire  to  spend 

or  give  away  large  sums  of  money. 

Rather  less  commonly  hesitation,  irritability,  depression, 

and  even  melancholia  are  the  leading  features. 


SYPHILITIC  DISEASES  OF  NERVOUS  SYSTEM     549 

The  mental  changes  progress  steadily  until  a  state  of 
complete  dementia  with  entire  loss  of  memory  and  lack 
of  interest  in  all  surroundings  is  reached. 

(ii.)  Cranial  Nerves.  The  pupil  changes  described  under 
"  Tabes  Dorsalis  "'  are  found  in  general  paralj'^sis,  with  the 
exception  that  the  complete  Argyll-Robertson  phenomenon 
is  rather  less  common.  Optic  atrophy  is  liable  to  occur,  as 
well  as,  occasionally,  partial  or  complete  ophthalmoplegia 
(from  basal  meningitis). 

(iii.)  Motor  System.  A  fine,  rapid  tremor  develops 
early  in  the  lips  and  tongue  and  spreads  later  to  the  hands 
and  arms.  The  speech  becomes  slurred  and  elisive,  a 
feature  which  is  best  shown  by  asking  the  patient  to  say 
sentences  involving  the  use  of  tongue  and  lips,  such  as  "The 
Royal  Irish  Constabulary  extinguishes  the  conflagration." 
Voluntary  power  gradually  diminishes  and  becomes 
completely  absent  in  the  latest  stages,  though  at  first  there 
tends  to  be  some  muscular  hypertonus. 

Epileptiform  seizures  are  a  prominent  feature  of  many 
cases  ;  they  may  be  Jacksonian  in  type,  generalised  or 
resembling  petit  maL  and  followed  by  asphasia. 

Each  convulsive  attack  tends  to  leave  the  general 
mental  condition  worse  than  before. 

(iv.)  Sensory  Symptoms.  There  is  no  constant  sensory 
change,  but  diffuse  })lunting  of  pain  sensibility  may  be 
observed. 

( v. )  The  Reflex  System.    The  knee  jerks  may  be  increased 
throughout,  or  after  an  initial  increase  they  may  diminish 
later.     In  tabo-paralysis  they  are  usually-  absent. 
The  superficial  reflexes  are  preserved   and  the  plantar 
reflex  is  of  the  flexor  type. 

The  sphincters  are  affected  quite  early,  as  in  tabes. 
Sexual  power  may  be  notably  increased,  but  equally  often 
is  lost. 

Diagnosis.  It  will  be  seen  that  the  clinical  picture  is 
characteristic  in  well-marked  cases.  Difficulty  may  arise  in 
the  following  cases  : — 

(a)  Neurasthenia.  There  are  no  ]m])illarv  changes  and 
no  speech  alteration. 

(6)  Cerebral  Syphilis.     There  is  no  exaltation,  no  speech 


550  MEDICAL  DIAGNOSIS 

alteration,  and  usually  there  are  definite  cranial  nerve 

palsies. 

(c)  Tumours  of  the  Frontal  Lobe  {vide  p.  524). 

{d)  Chronic  Alcoholisin.     The   history   of   alcohol   and 

the   condition  of    the   pupils    are    the    most    important 

points. 

In  any  case  of  doubt,  exainiyiation  of  the  cerebrospinal  fluid 
should  be  undertaken,  since  it  affords  positive  information 
of  the  presence  of  either  general  paralysis,  tabes  dorsalis, 
or  cerebral  syphilis  {vide  p.  511). 

Juvenile  General  Paraylsis.  This  presents  all  the  features 
of  the  adult  disease  ;  it  usually  develops  between  the  ages  of 
8  and  18,  and  always  in  congenital  syphilitics. 

The  stigmata  of  congenital  syphilis  {vide  p.  73)  can 
generally  be  recognised,  and  in  addition  there  is  often  more 
or  less  mental  deficiency. 


CHAPTER   VIII 

GENERAL  DISEASES  OF  THE  NERVOUS 
SYSTEM 

I.  Disseminated  Sclerosis.  This  is  a  chronic  progressive 
disease,  the  essential  lesion  being  the  occurrence  of  scattered 
patches  of  sclerosis  throughout  the  brain  and  cord. 

The  disease  usually  starts  in  young  adult  life,  but  may  not 
begin  until  after  40  years  of  age. 

The  sexes  are  affected  almost  equally,  men  being  slightly 
more  liable  than  women. 

The  pathology  is  obscure  ;  the  individual  patches  of 
sclerosis  are  sharply  defined  and  are  most  commonly  situated 
in  the  mid-brain,  centrum  ovale,  and  about  the  lateral 
region  of  the  spinal  cord,  though  they  may  develop  anywhere 
and  both  white  and  grey  matter  may  be  affected. 

Microscopically  the  most  striking  features  of  these  plaques 
are — a  dense  network  of  neuroglial  fibres,  absence  of  the 
myelin  sheaths  of  the  nerves,  and  retention  of  normal  axis- 
cylinder  processes. 

The  symptoms  and  signs,  of  course,  vary  with  the  different 
distribution  of  the  patches  of  sclerosis,  but  certain  features 
are  especially  constant  and  therefore  of  particular  diagnostic 
importance,  namely  : — 

(i.)  Nystagmus. 

(ii.)  Intention  tremor. 

(iii.)  (Scanning  or  staccato  speech. 

(iv.)  More  or  less  spastic  paraplegia  with  an  extensor 
])lantar  response. 

(v.)  Loss  of  superficial  abdominal  reflexes. 

An  important  point  is  the  tendency  for  remission  of  the 
earliest  s^-mptoms — for  example,  a  patient  may  suddenly 
develop  diplopia  or  amblyoi)ia  or  a  monoplegia,  which  nuiy 
completely  pass  off  in  a  few  days. 


552  MEDICAL   DIAGNOSIS 

The  following  are  the  more  common  manifestations  as 
they  affect  the  different  systems  : — 

(i.)  Mental.  The  patients  (especially  the  younger  ones) 
are  extremely  emotional,  and  often  quite  happy  and  opti- 
mistic ;  they  are  easily  moved  to  lavighter  or  to  tears.  At 
the  same  time  there  is  usually  definite  bluntmg  of  the  higher 
faculties. 

(ii.)  Cranial  Nerves.  Amblyopia,  hemianopia,  and  central 
scotoma  are  frequent. 

Optic  atrophy  occurs  in  nearly  50  per  cent,  of  all  cases. 

The  pupils  are  natural  and  react  to  light  unless  there  is 
optic  atrophy. 

Strabismus  may  occur  from  partial  ophthalmoplegia. 

Coarse,  irregular  nystagmus  is  nearly  always  present,  and 
is  best  seen  on  lateral  movement. 

Inco-ordination  of  the  articulatory  muscles  causes  the 
characteristic  staccato  or  syllabic  speech. 

(iii.)  Sensory  Systein.  Subjective  sensations  (numbness, 
tingling,  etc.)  are  often  present.  Objective  sensory  changes 
are  inconspicuous. 

(iv.)  Motor  System.  Spastic  paralysis  (upper  motor 
neuron)  is  the  rule  sooner  or  later  ;  it  is  most  evident  in  the 
lower  limbs,  where  it  assumes  a  paraplegic  form. 

Tremor  is,  perhaps,  the  most  constant  feature.  It  is 
not  evident  when  the  patient  is  at  rest,  but  at  once  appears 
on  voluntaij^  movement  (intention  tremor).  The  hands  and 
arms  show  the  tremor  best,  but  the  head  and  trunk  possess 
it  also  to  some  extent. 

(v.)  Reflexes.  The  superficial  abdominal  reflexes  are 
generally  lost  early.  The  deep  reflexes  are  never  lost  ; 
indeed,  they  are  usually  increased,  and  the  plantar  reflex 
becomes  extensor  as  soon  as  there  is  any  upper  motor 
neuron  lesion.  The  sphincters  are  not  constantly  affected 
unless  there  is  marked  paraplegia.  Precipitancy  or  retention 
may  occur,  and  constipation  is  apt  to  be  troublesome. 

(vi.)  Trophic  changes  are  rare. 

The  diagnosis  is  easy  in  a  well-developed  case,  but  difficulty 
may  arise  in  early  or  atypical  forms.  The  most  important 
conditions  to  be  distinguished  from  disseminated  sclerosis 
are  : — 


GENERAL   DISEASES   OF   NERVOUS   SYSTEM      553 

(a)  Hysteria.     A  transient  monoplegia  or  diplopia  is  apt 
to  be  regarded  as  functional.     The  most  important  points 
in  settling  that  a  case  of  this  sort  is  not  functional  are  : — 
(i.)  The  presence  of  nystagmus. 
(ii.)  The  absence  of  a  superficial  abdominal  reflex, 
(iii.)  The  presence  of  an  extensor  plantar  response, 
(iv.)  The  presence  of  optic  atrophy. 
Any    of    these    phenomena    are    important    evidence 
against  hysteria  ;  on  the  other  hand,  well-marked  evidence 
of  hysteria  may  be  present  in  cases  that  are  not  organic 
{vide  p.  585). 

{b)  Traumatic  Neurasthenia.  A  certain  proportion  of 
patients  with  disseminated  sclerosis  date  the  onset  of 
symptoms  from  an  accident,  and  it  may  well  happen  that 
inability  to  walk  properly  after  an  accident  may  be  attri- 
buted to  traumatic  neurasthenia  when  in  reality  the  case 
is  one  of  early  disseminated  sclerosis. 

(c)  Compression  Paraplegia.  This  can  be  distinguished 
by  the  sensory  loss  and  paralysis  up  to  a  certain  lev^el  and 
the  absence  of  nystagmus  or  tremor. 

(rf)  Subacute  Combined  Degeneration.  The  age  incidence 
is  later.  Sensory  changes,  subjective  and  objective,  are 
well  marked  ;  there  is  no  nystagmus  nor  optic  atrophy, 
and  usually  there  is  a  typical  blood  picture  (vide  p.  556), 

(e)  Extra -cerebellar  Tumour.  The  nystagmus  is  unequal, 
being  coarse  to  the  side  of  the  lesion  ;  there  is  likely  to  be 
ataxy  on  the  side  of  the  lesion  and  spasticity  on  the  other 
side  ;  optic  neuritis  may  be  present. 

(/)   Friedreich's  Disease  {ride  p.  563). 
II.  Amyotrophic    Lateral    Sclerosis.     This    is    a   chronic 
sclerosing   degeneration   of  both   u])])er   and    lower   motor 
neurons. 

In  most  cases  the  affection  is  very  much  more  marked 
in  the  lower  neurons  than  in  the  upper,  and  quite  often 
clinically  there  is  little  or  no  evidence  of  upper  neuron 
involvement.  This  condition  is  called  Progressive  3Iuscular 
Atrophy.  When  the  nuclei  of  the  cranial  nerves  are  involved 
by  extension  of  the  disease  up  the  cord  Bulbar  Paralysis 
results. 

Since  the  clinical  signs  vary  considerably  Avith  the  eitua- 


554  MEDICAL  DIAGNOSIS 

tioii  of  the  lesion,  the  disease  can  conveniently  be  described 
under  three  headings  : — 

(i.)  Progressive  Muscular  Atrophy.  This  is  a  disease 
which  affects  men  more  often  than  women,  and  rarely 
starts  before  30  years  of  age. 

The  first  sign  is  a  progressive  wasting  of  the  small  muscles 
of  the  hand.  This  is  usually  quite  marked  before  there  is 
any  very  conspicuous  loss  of  power,  but  after  a  time  weakness 
of  the  affected  muscles  is  a  prominent  feature. 

The  muscles  of  the  thenar  and  hypothenar  eminences, 
the  interossei,  and  the  lumbricals  are  the  first  to  be  affected, 
but  after  a  time  the  muscles  of  the  forearm  and  shoulder 
are  involved,  and  later  those  of  the  neck  and  also  of  the 
lower  limbs. 

One  hand  may  be  affected  before  the  other,  but  when  the 
case  comes  under  observation  the  condition  is  usually 
bilateral. 

Fibrillary  tremor  in  the  wasted  muscles  is  a  very  charac- 
teristic feature  of  the  disease. 

In  well-marked  cases  the  wasted  hands  assume  a  striking 
"  claw-like  "  appearance,  with  the  thumbs  retracted  into 
the  same  plane  as  the  fingers,  the  metacarpo-phalangeal 
joints  extended,  and  the  interphalangeal  joint  flexed. 

The  cranial  nerves  escape  unless  extension  of  the  disease 
up  the  cord  causes  bulbar  paralysis. 

The  sensory  system  is  unaffected. 

The  reflexes  gradually  disappear  in  the  affected  muscles  ; 
the  superficial  reflexes  are  unaltered. 

The  sphincters  escape. 

The  diagnosis  must  be  made  from  : — 

(a)  Cervical    Rib.  Here    the    lesion  is   unilateral,   the 

atrophy  does  not  progress,  there  are  sensory  changes, 

and  an  X-ray  photograph  may  show  the  rib. 

(6)  Muscular    Dystrophies.     Here    there    is    a   familial 

history,  a  younger  age  incidence,  different  distribution 

of  the  wasting,  and  no  fibrillation. 

(c)  Peroneal  Atrophy.  Except  that  there  is  fibrillation, 
the  same  remarks  apply  as  in  muscular  dystrophy,  and 
in  addition  there  is  sensory  change  {vide  also  p.  562). 

(d)  Peripheral  Nerve  Lesions.     In  these  pain  and  other 


GENERAL  DISEASES  OF  NERVOUS   SYSTEM     555 

sensory  disturb anccs  are  constant  if  a  mixed   nerve   is 

affected,    and   the   parah'sLs   is   of   peripheral    t3'pe,   not 

segmental. 

(ii.)  Amyotrophic  Lateral  Sclerosis.  In  addition  to  the 
features  of  anterior  horn-cell  degeneration,  as  described 
above,  there  is  a  degeneration  in  the  pyramidal  tracts  which 
usualty  develops  coincidently  with  the  muscular  atrophy. 

If,  then,  A\e  add  to  the  }>icturo  of  progressive  muscular 
atrophy  that  of  spastic  paralysis  of  the  legs  and  arms 
with  exaggeration  of  deep  reflexes,  absence  of  superficial 
abdominal  reflexes  and  extensor  plantar  responses  we  have 
the  characteristic  appearance  of  amyotrophic  lateral  sclerosis. 
There  is  no  sensory  change  and  usually  no  further  sphincter 
trouble  than  slightly-delayed  micturition  and  constipation. 

Very  rarely  it  happens  that  the  paraplegic  phenomena 
are  much  in  excess  of  the  atrophic  ones,  and  it  is  prob- 
ably to  such  cases  that  the  term  "'  primary  lateral  sclerosis  "' 
was  formerly  applied. 

The  diagnosis  presents  no  difficulties.  The  lack  of  sensory 
changes  excludes  sjTingo-myelia  and  tumours  whether 
intra-  or  extra-  medullary. 

(iii.)  Chronic  Bulbar  Paralysis.  This  is  merely  a  topical 
manifestation  of  progressive  muscular  atrophy  in  the  nuclei 
of  the  cranial  nerves  ;  it  is,  however,  practically  always 
associated  with  pyramidal  tract  involvement,  and  so  is 
usually  an  accompaniment  of  amyotrophic  lateral  sclerosis. 

If  the  upper  cranial  nerve  nuclei  are  affected  chronic 
oplithalmoplegia  is  added  to  the  picture  of  bulbar  palsy,  or 
it  may  exist  alone. 

The  special  signs  of  bulbar  paralysis  are  weakness  and 
wasting  of  the  tongue,  the  muscles  of  the  palate  and  pharynx, 
the  trapezius  and  sternomastoid  and  sometimes  the  muscles 
of  the  face.  In  a  well-developed  case  the  patient  cannot  put 
out  his  tongue,  swallow,  close  his  lips,  articulate  or  even 
whistle. 

The  diagnosis  must  be  made  from  : — 

(a)  Acute  Bulbar  Paralysis,  which  results  from  a  vas- 
cular lesion,  by  the  slow  and  insidious  onset. 

(h)  Myasthenia   Gravis    by   the   greater   atrophy,   the 

absence  of  remissions  in  the  signs,  the  absence  of  the 


556  MEDICAL   DIAGNOSIS 

mj'asthenic  reaction  {vide  p.  507),  and  the  presence  of  an 

evident  upper  motor  neuron  lesion. 

(c)  Former    Double  Heynijjlegia    by    the    lower   motor 

type  of  lesion  with  atrophj'  and  reaction  of  degeneration. 

III.  Subacute  Combined  Degeneration  of  the  Spinal  Cord. 
This  disease  consists  of  a  degeneration  of  the  white  matter 
of  the  spinal  cord,  which  generally  starts  in  the  posterior 
columns,  attacks  next  the  lateral  tracts,  and  may  in  the 
later  stages  spread  round  the  entire  white  matter  of  the 
cord.  The  signs,  however,  point  to  especial  involvement 
of  the  posterior  and  lateral  columns. 

The  degeneration  most  often  commences  in  the  lumbar 
region.  Associated  with  the  nervous  lesions  is  a  progressive 
anaemia,  which  is  generally  of  the  type  seen  in  Pernicious 
Anaemia. 

Women  are  affected  more  often  than  men,  and  the  age 
incidence  is  40  to  65  years. 

The  earliest  symptoms  are  the  subjective  sensory  pheno- 
mena of  numbness,  cold  and  tingling  in  the  extremities  ; 
these  are  usually  felt  in  the  feet  before  the  hands,  and  may 
last  for  many  months  before  any  other  signs  appear. 

The  next  symptoms  are  progressive  spastic  paralysis  in 
the  legs  and  anaemia.  As  the  spasticity  develops  there  are 
often  cramps  and  flexor  spasms.  The  sphincters  are  affected 
to  a  slight  extent  about  this  time,  but  there  is  not  inconti- 
nence at  this  stage.  An  absent  superficial  abdominal 
reflex  and  an  extensor  plantar  response  are,  as  usual, 
likely  to  be  the  earliest  signs  of  commencing  paraplegia. 

By  the  time  that  there  is  definite  paraplegia  there  is 
usually  objective  sensory  loss  up  to  a  definite  segmental 
level,  although  subjective  phenomena  of  numbness,  sense 
of  contraction,  etc.,  may  be  present  also. 

The  upper  level  of  the  lesion  can  often  be  traced  in  its 
advance  up  the  cord  by  the  increase  upwards,  segment  by 
segment,  of  the  anaesthesia. 

When  this  stage  is  reached  death  is  not  far  off,  but  before 
this  happens  there  is  a  change  in  the  type  of  the  paraplegia, 
which  becomes  utterly  flaccid,  with  loss  of  all  reflexes, 
except  possibly  the  extensor  plantar  response  which  may 
persist  till  the  end,  and  complete  incontinence. 


GENERAL   DISEASES   OF   NERVOUS   SYSTEM      557 

Before  the  patient  is  bedridden  the  picture  is  one  of 
ataxic  paraplegia  from  the  predominance  of  the  "  postero- 
lateral "  sclerosis. 

The  ordinary  duration  of  the  disease  is  not  more  than 
two  or  three  years  and  may  be  much  less. 

Differential  diagnosis  must  be  made  from — 

(a)   Tabes  Dorsalis.     By  the  absence  of  eye  change  or 

special  loss  of  muscle  sensibility  and  the  presence  of  an 

extensor  plantar  response. 

{b)  Disseminated  Sclerosis  {vide  p.  553). 

(c)  Syphilitic  Men  ill  go-myelitis.     By  the  absence  of  any 

eye  signs  or  of    lymphocyte  sis  in  the  cerebro-spinal  fluid, 

by  the  blood  picture,  and  by  the  character  and  distribution 

of  the  sensory  changes. 

IV.  Acute  Poliomyelitis.  This  is  a  specific  infective  di^^ase 
occurring  in  ej)ideniics  (especially  in  Northern  Europe), 
but  also  sporadically,  and  affecting  children  and  young  adults. 

The  micro-organism  is  believed  to  be  an  ultra -microscopic 
coccus  ;  the  virus  has  been  isolated  and  used  to  produce 
the  typical  disease  in  animals. 

The  lesions  characteristic  of  the  disease  are  acute  inflam- 
matory foci  round  the  blood-vessels  in  the  grey  matter  of 
the  cord  anywhere  throughout  its  entire  length.  The 
anterior  horn-cells  are  those  principally  affected,  but  there 
is  in  fatal  cases,  and  possibly  in  all,  a  similar  change  locally 
in  the  vessels  of  the  pia-arachnoid.  Acute  encephalitis  is 
the  same  disease  affecting  the  cortex  of  the  brain. 

The  cerebro-spinal  fluid,  except  in  the  mildest  cases, 
shows  a  definite  lymphocytosis. 

The  symptojns  start  abruptly,  with  the  usual  constitu- 
tional disturbance  of  specific  infections,  fever,  malaise  and 
])ains  in  the  head  and  limbs  ;  vomiting  and  convulsions 
occur  in  the  more  severe  cases. 

In  addition  to  the  pains  in  the  limbs  tiie  muscles  are  often 
tender. 

The  constitutional  disturbance  may  be  so  slight  as  to  be 
overlooked  by  inattentive  parents  and.  anyhow,  subsides 
in  a  few  days. 

Within  a  short  time  of  the  onset  of  the  illness  there  is  a 
flaccid  paralyses  of  some  of  the  voluntary  nuiscles. 


558  MEDICAL   DIAGNOSIS 

The  paralysed  muscles  may  be  few  or  many  ;  most  often 
the  limb  muscles  are  picked  out  ;  the  trunk  muscles  are 
quite  often  affected  and  the  muscles  supplied  by  the  cranial 
nerves  much  more  rarely. 

The  muscles  are  affected  according  to  their  segmental 
cord  supply,  thus  showing  clearly  that  the  lesions  are  in  the 
anterior  horns. 

There  is  considerable  wasting  of  the  paralysed  muscles, 
with  loss  of  reflexes  and  reaction  of  degeneration. 

The  initial  paralysis  is  always  far  greater  than  the  per- 
manent ;  this  can  be  explained  by  the  ultimate  recovery 
of  many  nerve  cells  which  are  temporarily  put  out 
of  action  by  adjacent  inflammatory  exudate.  There 
are,  however,  practically  always  some  permanent  muscular 
paralyses  left  when  the  maximum  of  recovery  has  been 
made. 

As  the  child  grows  up  contracture  deformities  are  prone 
to  develop,  usually  from  over-action  of  the  unparalysed 
muscle  groups. 

The  Sensory  System  usually  escapes,  but  this  is  by  no 
means  always  the  case,  and  the  presence  of  sensory  pheno- 
mena pointing  to  a  posterior  horn  lesion  should  not  vitiate 
the  diagnosis  provided  that  the  motor  signs  are  those  of 
poliomyelitis. 

The  sphincters  are  but  rarely  affected,  though  retention  of 
urine  may  occur  at  the  outset. 

Vaso-motor  and  trophic  changes  show  themselves  by  cold- 
ness and  lividity  of  the  affected  parts,  and  by  a  tendency 
for  impaired  growth  subsequently  in  severe  cases. 

If  the  bulbar  muscles  are  aifected  an  acute  bulbar  paralysis 
results,  and  must  be  diagnosed  by  the  constitutional  dis- 
turbance and  possibly  by  the  evidence  of  poliomyelitis 
elsewhere.  As  a  rule  the  diagnosis  is  not  difficult  if  the  age 
of  the  patient  and  the  presence  of  the  initial  constitutional 
disturbances  are  remembered. 

Landry's  Paralysis  affects  adults,  starts  gradually,  and 
spreads  steadily  upwards  from  the  lower  limbs  ;  there  is 
no  atrophy  and  but  little  constitutional  disturbance. 

In  Acute  Toxic  Polyneuritis  adults  are  affected,  there  is 
usually  no  constitutional  disturbance,  but  marked  sensory 


GENERAL  DISEASES   OF   NERVOUS   SYSTEM      559 

ayni'ptoms  oi  peripheral  type  occur.     A  nuclear  arrangement 
of  the  paralysed  muscles  is  not  present. 

V.  Landry's  Paralysis.  This  is  thought  to  be  due  to  the 
action  of  some  toxin  on  the  anterior  horn-cells  of  the  spinal 
cord.  It  occurs  between  the  ages  of  20  and  40  years  and 
affects  men  more  than  women. 

The  onset  is  attended  by  slight  constitutional  disturbance. 
In  a  few  hours  there  is  a  sense  of  heaviness  in  one  or  both 
legs,  which  soon  develops  into  a  flaccid  paralysis.  The 
paralysis  may  affect  the  proximal  segments  of  the  limb  before 
the  distal,  and  in  very  rare  cases  the  arms  are  attacked  before 
the  legs. 

The  motor  paralysis  is  complete  for  all  muscles,  and  spreatls 
steadily  up  the  trunk  until  the  respiratory  muscles  are 
affected  and  even  the  muscles  supplied  by  the  cr«inial 
nerves. 

Death  usually  takes  place  in  from  two  to  five  days,  but 
sometimes  the  upward  course  of  the  disease  stops  suddenly, 
and  in  these  cases  recovery  may  be  complete. 

The  deep  reflexes  are,  of  course,  absent  over  the  paralysed 
area.     The  superficial  reflexes  may  be  preserved. 

The  sphincters  are  not  affected. 

There  is  no  sensory  loss. 

The  differential  diagnosis  must  be  made  from — 
(a)  Acute  toxic  polyneuritis  {vide  p.  510). 
(6)  Acute  poliomyelitis  {vide  p.  558). 


CHAPTER    IX 

FAMILIAL  DISEASES 

In  this  chapter  will  be  included  those  diseases  of  the 
nervous  system  which  are  congenital  and  those  which  have 
a  familial  incidence. 

I.  The  Muscular  Dystrophies.  The  name  "  Dystrophy  " 
is  given  to  a  group  of  cases  in  which  there  is  a  congenital 
muscular  defect  whereby  certain  muscles  are  unable  to 
develop  in  proportion  with  the  rest  of  the  body  or  in  which 
certain  muscles  or  parts  of  certain  muscles  are  absent  at 
birth.  There  is  nearly  always  evidence  of  a  familial  distri- 
bution and  the  disease  is  transmitted  by  an  unaffected 
mother.  Clmically  the  following  varieties  of  muscular 
dystrophy  may  be  recognised  :■ — • 

(i.)  Pseudo-hypertrophic  Muscular  Paralysis.  This  affects 
males  more  than  females  and  usually  is  first  noticed  at  the 
age  of  four  to  five  years  ;  an  onset  later  than  twelve  years  is 
rare. 

Difficulty  and  unsteadmess  in  walking  are  the  first 
signs  ;  the  child  falls  readily  and  gets  up  with  difficulty. 
It  may  be  noticed  that  his  gait  becomes  waddling  owing 
to  the  wide  separation  of  the  feet.  There  is  marked 
lumbar  lordosis,  and  the  shoulders  are  thrown  back  in 
order  to  relieve  the  quadriceps  femoris  as  much  as  possible. 

The  mode  of  rising  from  the  floor  by  climbing  up  himself 
is  very  characteristic  ;  the  child  rolls  over  on  to  his  hands  and 
knees,  he  extends  his  knees  so  that  his  toes  and  hands 
only  are  on  the  floor,  and  then  places  one  hand  above  its 
corresponding  knee  and  gradually  works  it  up  the  thigh  as 
the  sole  of  that  foot  becomes  flat  on  the  ground.  A  similar 
manoeuvre  is  now  gone  through  with  the  other  hand,  until 
with  a  jerk  the  shoulders  are  thrown  back  and  he  is  standing 
up. 

Certain  muscles  appear  to  be  hypertrophied  in  the  earlier 


FAIVIILIAL  DISEASES  561 

stages,  though  the  hypertrophy  is  unreal  and  is  made  up 
of  fat  and  fibrous  tissue.  These  muscles  are:  the  calf 
muscles,  the  extensors  of  the  knee,  the  glutsei,  the  lumbar 
muscles,  the  supra-  and  infra-  spinati,  the  deltoid,  the  triceps 
and  biceps. 

Certain  muscles  waste  without  any  preliminary  p.seudo- 
hypertrophy  or  may  be  congenitally  ab.sent.  These  are: 
the  latissimus  dorsi,  the  teres  major,  the  clavicular  half 
of  the  sterno-mastoid,  and  the  lower  part  of  the  pectoralis 
major. 

The  child  is  unable  to  depress  his  arms  against  resistance 
and  cannot  be  lifted  up  by  hands  placed  in  his  axilla},  with- 
out tending  to  slip. 

The  reflexes  diminish  as  the  muscle  fibres  waste  :  the 
electrical  respon.ses  in  the  affected  muscles  do  likewise.  / 

The  sphincters  are  not  mvolved,  and  there  is  no  sensory 
change. 

There  is  no  fibrillary  tremor  in  the  affected  muscles. 

In  some  cases  the  mu.scles  affected  are  the  same  as  described 
above,  but  the  disease  is  atrophic  from  the  start. 

(ii.)  Erl/s  Juvenile  Type  oj  Muscular  Dystrophy.  In  this 
variety  the  onset  occurs  between  the  ages  of  12  and  20 
years  ;  the  condition  is  usually  atrophic  from  the  first,  but 
maj'  show  pseudo-hypertrophy  sometimes. 

The  first  changes  are  seen  in  the  muscles  of  the  shoulder- 
girdle,  namely,  the  lower  part  of  pectoralis  major,  the 
trapezius,  the  serratus  magnus,  the  latissimus  dorsi,  and  the 
rhomboids.  The  following  arm  muscles  are  affected  also  : 
t  he  biceps,  the  triceps,  and  the  supinator  longus.  The  spmati 
and  the  deltoid  are  generally  unaffected.  Later  the  mu.scles 
of  the  ])elvic  girdle  and  the  back  and  trunk  become  involved. 

(iii.)  The  Facio-scapulo-humeral  Type  of  Landouzy- 
Dejerine.  This  variety  affects  the  sexes  equally  and  starts 
at  or  soon  after  puberty.  The  first  muscles  to  be  affected 
are  the  face  nuiscles,  especially  the  risorii,  orbiculares, 
levatores  menti,  and  zygomatici.  The  nasolabial  folds  are 
obliterated,  the  li])s  turn  out  and  cannot  be  "  pursed  "  as 
in  whistling,  and  the  articulation  of  labials  iH  im])ossible. 

Later  the  muscles  of  the  shoulder  girdle  and  ujipcr  aim 
become  affected  also, 

M.D.  36 


562  MEDICAL   DIAGNOSIS 

Other  rarer  and  less  important  varieties  are  described, 
such  as  a  Distal  type,  in  which  the  small  muscles  of  the 
extremities  are  first  affected,  and  the  Pelvic  type,  in  which 
weakness  of  the  psoas  muscles  causes  difficulty  in  walking 
upstairs  before  any  other  symptoms  are  apparent. 

It  may  be  stated  that,  in  whatever  form  the  disease 
starts,  there  is  a  steadily  progressive  tendency,  and  more 
and  more  muscle  groups  are  likely  to  be  involved  before 
death  takes  place.  This  is  usually  due  to  some  intercurrent 
pulmonary  affection,  probably  from  ten  to  twenty  years 
after  the  first  symptom. 

The  diagnosis  must  be  made  from — 

(a)  Peripheral  Nerve  Lesions,  by  the  absence  of  sensory 

symptoms,  the  age  of  onset,  and  the  distribution  of  the 

atrophy. 

(6)  Progressive    Muscular    Atrophy,    by    the    familial 

history,  the  earlier  age,  the  different  distribution,  the  gait, 

and  the  absence  of  fibrillation  or  reaction  of  degeneration. 
(c)  Myasthenia  Gravis  {vide  p.  567). 

II.  Peroneal  Muscular  Atrophy.  This  disease  is  not  a 
muscular  dystrophy  ;  it  is  included  in  this  chapter  because 
of  its  familial  incidence.  Pathologically  the  principal 
changes  are  those  of  degeneration  of  the  mixed  nerves  and 
also  of  the  anterior  horn-cells,  but  there  is  degeneration  to  a 
lesser  extent  m  the  posterior  roots  and  the  posterior  columns. 

The  course  is  very  chronic  ;  symptoms  are  usually  first 
noticed  between  the  ages  of  15  and  35  years,  and  males  are 
more  often  affected  than  females. 

The  first  signs  are  wastmg  of  the  peroneal  muscles,  the 
small  muscles  of  the  feet,  and  to  some  extent  the  long  ex- 
tensors of  the  toes.  Later  the  calf  muscles  may  become 
involved. 

The  appearance  of  the  leg  is  characteristic  :  the  leg  is 
wasted  below  the  knee  and  the  outer  border  is  notably  flat, 
the  thigh  muscles  are  large  and  give  to  the  leg  rather  the 
appearance  of  an  Indian  club. 

The  toes  are  pointed  and  the  foot  turned  in  ;  often  there 
may  be  talipes  equinus  or  equino-varus. 

Fibrillary  twitching  and  some  reaction  of  degeneration  can 
generally  be  demonstrated. 


FAMILIAL   DISEASES  563 

The  nerves  are  not  tender,  but  occasionally  pain  is  com- 
plained of,  and  some  blunting  of  sensation  can  practically 
always  be  found  on  the  peroneal  aspect  of  the  leg. 

The  sphincters  escape. 

A  late  manifestation  of  the  disease  may  be  the  appearance 
of  similar  atrophy  in  the  muscles  of  the  hands  and  forearms. 

The  age  of  onset,  the  family  history,  and  the  very  charac- 
teristic distribution  should  prevent  any  error  in  diagnosis. 

III.  Friedreich's  Disease.  This  disease  is  usually  familial, 
but  apparently  sporadic  cases  may  occur.  It  is  not  as  a 
rule  transmitted  directly  by  an  affected  parent.  Males  are 
attacked  more  often  than  females. 

The  first  signs  generally  appear  from  7  to  17  years  of  age. 
The  essential  pathology  is  a  progressive  sclerosis  in  the 
spino-cerebellar  tracts  and  in  the  posterior  and  lateral 
columns  of  the  cord. 

The  characteristic  features  of  Friedreich's  Disease  are  : — 
{a)  Cerebellar  type  of  ataxy,  reeling  gait,   and  mco- 

ordination  of  voluntary  movements. 

(b)  Tremor  of    hands,    head,  and   trunk   (mostly  voli- 
tional). 

(c)  Nystagmus,  but  no  alteration  of  light  reflex  except 
in  the  rare  cases  in  which  optic  atrophy  develops. 

{d)  Deliberate,  scanning,  explosive  speech, 
(e)  Scoliosis. 

(/)  Pes  cavus,  with  conspicuous  over-extension  of  the 
great  toe. 

(g)  Absent  knee  jerks  and  usually  absent  superficial 
abdominal  reflexes. 

(k)  Extensor  plantar  response. 
As  a  rule  there  is  no  sphincter  trouble  or  sensory  disturb- 
ance, but  sometimes  cram])-like  pains  are  described.     The 
mental  condition  frequently  shows  a  .slight  dulness. 

In  a  typical  case  the  clinical  picture  is  sufficiently  obvious, 
but  it  must  be  remembered  that  the  disease  is  extremely 
chronic  and  that  only  one  or  two  signs  may  be  present  for 
considerable  periods.  Thus  pes  cavus  may  be  the  first  sign 
in  one  case  and  clumsiness  m  walking  in  another  or  nys- 
tagmus in  a  third. 
Tlie  combination  of  nystagmus,  scoliosis,  pes  cavus,  and 

36—2 


564  MEDICAL  DIAGNOSIS 

an  extensor  plantar  response  with  absent  knee  jerks  is  more 
than  suggestive. 

It  happens  occasionally  that  Friedreich's  disease  may  first 
manifest  itself  by  ataxic  paraplegia,  increased  deep  reflexes, 
nystagmus,  scanning  speech,  and  even  sphincter  trouble. 
Except  for  the  probable  younger  age  of  the  patient  such 
cases  cannot  be  distinguished  from  disseminated  sclerosis. 
In  time,  however,  the  development  of  scoliosis  and  pes  cavus 
and  the  loss  of  the  deep  reflexes  will  enable  a  correct  diag- 
nosis to  be  made.  In  such  cases  a  careful  investigation 
into  the  family  history  might  suggest  the  true  state  of  affans. 

IV.  Cerebellar  Ataxia.  Under  this  title  may  be  grouped 
a  variety  of  rare  conditions  some  of  which  are  hereditary 
or  familial. 

The  .outstanding  clinical  features  are  : — 

{a)  A  cerebellar  ataxy,  as  shown  by  the  reeling  gait. 
(6)  Inco-ordination  or  tremor  of  the  arms, 
(c)  Scanning  or  explosive  speech. 
{(l)  Usually  nystagmus. 

V.  Familial  Spastic  Paraplegia.  This  hereditary  or 
familiar  disease  is  due  to  progressive  degeneration  in  the 
lateral  tracts  of  the  cord.  It  usually  develops  between  the 
ages  of  7  and  10  years.  The  symptoms  are  those  of  pure 
spastic  paraplegia,  but  sphincter  disturbance  is  slight. 
Occasionally  the  arms  are  involved  later.  The  family 
history,  the  later  onset,  the  progressive  course,  and  the 
absence  of  mental  impairment  distinguish  this  condition 
from  the  paraplegic  type  of  cerebral  diplegia. 

VI.  Huntingdon's  Chorea.  This  rare  disease  is  strongly 
hereditary.  It  develops  between  the  ages  of  30  and  40. 
The  symptoms  are  choreiform  movements  combined  with 
a  steadily  progressive  mental  impairment,  leading  eventually 
to  complete  dementia.  A  considerable  number  of  patients 
who  suffer  from  this  disease  commit  suicide. 

VII.  Amaurotic  Family  Idiocy.  This  disease  is  often 
familial  and  appears  only  to  occur  in  the  Jewish  race.  The 
child  is  born  healthy,  but  when  a  few  months  old  develops 
optic  atrophy  and  a  spastic  paralysis  of  the  limbs,  especially 
noticeable  in  the  hands.  The  optic  discs  show  a  cherry  red 
spot  at  the  macula.     Death  occurs  within  two  years. 


FA^IILIAL   DISEASES  565 

VIII.  Myotonia  Congenita  (Thomsen's  Disease).  This 
familial  disease  develops  in  childhood  and  shows  itself  by  a 
delay  in  the  relaxation  of  voluntary  muscles  after  contrac- 
tion or  in  making  an  initial  movement  after  a  period  of  rest. 
The  muscles  are  well  developed  and  show  an  increased  ex- 
citability to  stimulation  of  all  sorts.  After  a  certain  number 
of  movements  have  been  performed  the  stiffness  and 
rigidity  wears  off  for  the  rest  of  the  time  that  the  exercise  is 
continued. 

IX.  Amyotonia  Congenita. — This  rare  condition  shows 
itself  soon  after  birth  by  a  definite  lack  of  muscular 
tone.  All  sorts  of  abnormal  attitudes  are  assumed  with 
ease.  Sucking  may  be  impossible,  and  in  later  years 
hypotonus  of  the  back  muscles  may  make  the  sitting  posture 
difficult.  / 

X.  Myotonia  Atrophica,  This  rare  condition  does  not 
develop  till  after  puberty  :  there  is  difficulty  in  relaxing 
the  muscles  of  the  extremities,  face,  and  neck  after  contrac- 
tion. The  muscles  are  wasted,  and  this  fact,  with  the  later 
age  of  onset,  serves  to  exclude  Thomsen's  disease. 


CHAPTER    X 
DISORDERS  OF  MUSCULAR  FUNCTION 

I.  Myasthenia  Gravis.  This  disease  is  characterised  by 
the  development  of  easy  fatigue  in  certain  muscle  groups. 
It  may  commence  at  any  age  after  childhood,  is  not  familial, 
and  seems  to  affect  the  sexes  equally. 

The  pathology  is  obscure  ;  collections  of  small  round 
cells  have  been  described  in  the  affected  muscles  and  also 
in  the  liver,  kidneys,  and  around  the  nerve  cells  of  the  bulbar 
nuclei.     The  thymus  is  persistent. 

Course.  The  condition  is  subacute  or  chronic  ;  mild 
cases  may  last  many  years  :  on  the  other  hand,  v/hen  many 
muscles  are  affected  death  usually  occurs  within  two  or 
three  years. 

Symptoms.  The  earliest  and  most  constant  symptom 
is  a  weakness  of  the  facial  and  external  ocular  muscles,  which 
is  induced  or  markedly  increased  by  exertion  and  is  worse  at 
the  end  of  the  day.  The  muscles  of  the  palate  and  of  articu- 
lation may  be  affected  in  the  same  way,  so  that  slurring 
speech  and  difficulty  in  swallowing  may  be  present.  The 
tongue  is  soft  and  flabby  and  shows  three  longitudinal 
furrows,  one  central  and  two  lateral. 

Any  special  occupation  may  determine  the  onset  of 
myasthenic  symptoms  elsewhere  than  in  the  muscles  supplied 
by  the  cranial  nerves,  but  these  will  become  affected  before 
long. 

The  early  symptoms  are  often  conspicuously  remittent 
and  may  for  this  reason  lead  to  a  diagnosis  of  hysteria.  In 
more  severe  cases  the  affection  spreads  to  the  muscles  of 
the  neck  and  shoulders,  while  in  really  advanced  cases  the 
muscles  of  the  back,  trunk  and  extremities  are  affected  also. 

The  sensory  system  is  not  affected. 

The  reflexes  show  no  characteristic  change,  but  the  deep 


DISORDERS   OF  MUSCULAR   FUNCTION      567 

reflexes   may   temporarily   fail   to   respond   after   repeated 
elicitation. 

The   vasomotor    system    seems    to   be    excitable,    since 
flushing  and  sweating  are  common. 

The  mental  state  is  not  profoundly  altered,  but  myasthenic 
patients  are  usually  somewhat  emotional. 
Special  Diagnostic  Features  : — 

(a)  The  Character  and  Distribution  of  the  Symptoms. 
The  weakness  of  certain  groups  of  muscles  without 
notable  wasting,  and  the  fact  that  after  rest  these  muscles 
are  capable  of  considerable  effort  whilst  use  soon  tires 
them  out. 

(6)  The  Fades.  There  is  usually  some  ptosis  ;  the 
forehead  is  smooth  and  the  head  tilted  back  :  the  expres- 
sion appears  to  be  sneering  ;  the  lips  are  slightly  parted, 
the  upper  one  is  retracted  and  the  lower  one  slightly 
everted,  while  the  corners  of  the  mouth  droop. 

The  patient  cannot  wrinkle  his  forehead,  shut  his  eyes 
tightly,  or  "purse"  his  lips. 

(c)  Electrical  Reactions.  A  faradic  current  excites  a 
brisk  contraction,  but  this  soon  fades  and  disappears  if 
the  current  is  continued.  After  a  definite  period  of  rest 
the  muscles  can  again  respond  to  renewed  excitation  in 
the  same  manner. 

This  is  known  as  the  mya.sthenic  reaction. 

{(1)  I J  'ealcn  ess  of  th  e  Shou  Ider  Muscles  makes  it  impossib  le 
to  keep  the  arms  raised  from  the  side  for  any  appreciable 
time,  and  after  this  has  been  essayed  once  or  twice  the 
arms  cannot  be  raised  at  all  without  a  long  rest. 

Myasthenia  gravis  must  be  distinguished  from — 

(i.)  Facio-Scapulo-Humeral  type  of  muscular  dystrophy, 
by  the  absence  of  atrophy  or  of  partial  reaction  of  degenera- 
tion and  by  the  history  of  remissions  and  the  presence  of 
the  myasthenic  electrical  reaction. 

(ii.)  JI listeria,  by  the  absence  of  any  hysterical  stigmata, 
by  the  onset  of  the  symptoms  at  night  or  after  exercise, 
and  by  the  myasthenic  reaction. 

(iii.)  Bulbar  Palsy .  by  the  absence  of  atrophy  and  by  IIk^ 
history  of  remissions. 
11.   Paramyoclonus     Multiplex.       This     lare     tliseasc     is 


568  MEDia\L   DIAGNOSIS 

characterised  by  the  occurrence  of  frequent  "  shock-hke  " 
contractions  in  single  muscles  or  portions  of  muscles  or, 
very  occasionally,  in  groups  of  muscles. 

The  muscles  of  the  upper  arms  or  thighs  are  most  often 
affected  and  the  condition  is  bilateral.  The  contractions 
cease  in  sleep.  There  is  no  associated  sensory  or  mental 
change. 

The  pathology  is  unknown. 


CHAPTER    XI 

DISORDERS  OF  MOTION 

I.  Paralysis  Agitans  (Parkinson's  Disease).     The  pathology 
of  this  disease  is  obscure.     The  onset  between  the  ages  of 
40  and  70  years  suggests  the  possibility  of  there  being  some 
underlying  degenerative  factor,  possibly  in  the  muscles. 
The  characteristic  clinical  features  are  : — 
(i.)  Muscular  rigidity, 
(ii.)   Coarse  rhythmical  tremor. 
In  a  given  ca.se  either  of  the.se  features  may  be  present  to 
the   exclusion    of   tlie   other  ;  usually   they    are   both   well 
marked. 

(i.)  Muscular  Riijidity.  This  is  usually  the  first  sign  ; 
it  is  v/idespread,  but  does  not  amount  to  spasticity,  and  an 
extensor  plantar  response  is  never  present.  With  the 
rigidity  is  associated  a  slight  muscular  weakness.  As  a 
direct  consequence  of  the  muscular  rigidity  and  weakness 
the  following  signs  develop  :  - 

(a)  Mask-like  Expression  (Parkinson's  Mask).  Im- 
mobility of  the  facial  muscles  and  replacement  of  ordinary 
emotional  feature-play  by  a  tense,  anxious  expression. 
(6)  Monotonous  deliberate  articulation, 
(c)  Attitude.  This  is  very  characteristic.  TIk^  head  is 
bent  forwards,  the  back  is  held  stiff  and  curved  forwards, 
the  elbows  carried  close  to  each  oth'^r  in  front  of  the 
abdomen,  with  the  fingers  bent  at  the  mctacarpo-phalan- 
geal  joints,  but  extended  at  the  inteiphdangeal  joints. 
The  knees  are  slightly  flexed  and  the  thighs  tend  to  be 
adducted. 

(r7)  The  gait  is  slov/  and  hesitating,  but  when  move- 
ment has  started  it  tends  to  brcomo  more  rapid  owing  to 
displacement  of  the  centre  of  gravity  and  an  apparent 
attempt  to  catch  this  up  again  (fe.stination). 


570  MEDICAL  DIAGNOSIS 

(ii.)  Tremor.  This  is  coarse  and  rhythmical  and  at  first 
best  seen  in  the  thumb  and  forefinger,  which  perform  the 
typical  "bread-crumbling  "  movements.  Analogous  move- 
ments may  be  performed  at  the  wrist  and  ankle  joints. 
Head  nodding  is  often  observed.  Movements  of  the  jaws 
are  less  common.  In  the  lower  limb  the  tremors  tend  to 
be  proximal  rather  than  distal  at  the  outset.  The  tremors 
continue  when  the  patient  is  at  rest,  but  cease  with  volun- 
tary movement  and  can,  in  early  cases,  be  controlled  by 
an  effort  of  Avill. 

The  tremor  usually  starts  in  one  hand  and  affects  the  leg 
of  the  same  side  before  spreading  to  the  opposite  hand. 

The  reflexes  are  brisk  but  well  within  normal  limits  ; 
there  is  no  sphincter  loss. 

There  is  no  objective  sensory  loss,  but  subjective  sensations 
of  temperature  change  and  vague  aching  are  not  uncommon. 

In  well-developed  cases  the  clinical  picture  of  paralysis 
agitans  does  not  commonly  leave  roomfor  mistaken  diagnosis ; 
the  following  conditions  should,  however,  be  excluded  : — 

(1)  Bilateral  Cortical  Degeneration.  In  this  the  pro- 
gressive bilateral  rigidity  and  fixed  expression  closely 
resemble  Parkinson's  disease  ;  the  progressive  mental 
deterioration  and  eventually  the  development  of  an  extensor 
plantar  response  should  prevent  mistake. 

(2)  Senile  Tremor  occurs  at  an  even  later  age  ;  it 
involves  especially  the  head,  is  bilateral  from  the  outset, 
and  is  not  associated  with  rigidity. 

(3)  Double  Hemijilegia  gives  clear  evidence  of  organic 
disease,  as  shown  by  the  alteration  in  the  reflexes. 

II.  Chorea.  Chorea  is  a  disease  of  childhood  and  adoles- 
cence. That  it  is  a  manifestation  of  rheumatism  seems  no 
longer  open  to  doubt.  More  than  30  per  cent  of  all  cases 
have  endocarditis,  while  more  than  80  per  cent,  give  a  history 
of  ordinary  rheumatism  or  show  other  signs  of  rheumatic 
infection.     Girls  are  affected  more  frequently  than  boys. 

An  interesting  point  is  the  tendency  for  chorea  and  epi- 
lepsy to  predispose  to  one  another. 

Symptoms.  The  earliest  symptom  is  an  alteration  in 
the  mental  condition  of  the  child  ;  she  becomes  irritable, 
nervous,  emotional,  and  unable  to  fix  the  attention.     The 


DISORDERS   OF   MOTION  571 

next  symptom  is  usually  clumsiness,  Avith  a  tendency  to 
drop  things  and  to  fidget  excessively  ;  this  is  due  to  muscular 
inco-ordination. 

It  is  not  unnatural  that  these  early  symptoms  should 
often  be  ascribed  to  naughtiness  and  the  child  punished 
unjustly. 

The  characteristic  choreiform  movements  usually  appear 
first  in  the  hands  and  arms,  next  in  the  face,  and  lastly 
in  the  legs  and  trunk.  Sometimes  the  movements  are  uni- 
lateral (hemi-chorea)  throughout.  The  actual  movements 
are  produced  by  sudden,  jerky,  irregular  contractions  of 
groups  of  muscles  ;  they  are  not  limited  to  one  group,  but 
seem  haphazard.  The  contractions  are  not  clonic.  The 
movements  are  more  marked  when  the  child  is  excited  or 
when  she  is  being  observed  ;  they  usually  subside  during 
sleep.  Occasionally  the  movements  are  so  continuous  and 
wild  that  a  padded  bed  is  necessary  to  prevent  injury. 

There  is  no  atrophy  of  the  muscles,  but  there  is  definite 
motor  weakness,  which  may  be  so  extreme  as  to  simulate 
paralysis. 

The  muscular  inco-ordination  often  produces  an  alteration 
in  the  speech  which  becomes  hurried,  indistinct,  and  inter- 
rupted. 

The  Mental  Condition  is  not  often  more  altered  than 
indicated  above,  but  in  very  severe  cases  a  condition  of 
maniacal  excitement  may  supervene. 

The  expression  is  characteristically  bright,  eager,  and  full 
of  nervous  tension. 

The  Sensory  System  is  unaffected.  Pains  in  the  limbs, 
if  present,  are  due  to  rheumatism. 

The  Reflexes  are  brisk  ;  the  knee  jerks  are  well  sustained 
in  many  cases.  There  is  no  sphincter  trouble  unless  mania 
develops. 

The  diagnosis  of  chorea  presents  no  diflficulty  as  a  rule  ; 
very  mild  cases  may  be  overlooked  unless  a  careful  history 
is  obtained,  and  it  is  important  to  remember  that  the 
})aralytic  form  in  which  there  is  marked  muscular  weakness 
may  show  but  little  of  the  typical  movements. 

Hal)it  .spasms  may  be  mistaken  for  chorea,  but  a  habit 
spasm  is  the  constant  repetition  of  the  same  "  purposive  " 


572  MEDICAL   DIAGNOSIS 

co-ordinated  movement,  whilst  choreic  movements  are  not 
really  pvirposive,  and  tlie  same  movement  is  only  reproduced 
by  accident  amongst  many  others.  At  the  same  time 
children  with  chorea  are  rather  liable  to  have  some  form 
of  "  tic  "  or  habit  spasm  as  well. 

In  Paramyoclonus  Multiplex  the  individual  contractions  are 
much  more  violent  ;  they  are  more  likely  to  affect  a  single 
muscle  than  a  muscle  group,  and  tend  specially  to  pick  out 
certain  muscles.     There  is  no  mental  change. 

Chorea  occurring  in  pregnancy  shows  the  same  features 
as  ordinary  chorea,  and  is  equally  a  manifestation  of  rheu- 
matism. 

III.  Tetany  (Carpo-pedal  Spasm).  Tetany  is  shown  by 
the  occurrence  of  bilateral  tonic  spasms  in  the  muscles  of 
the  extremities,  and  sometimes  of  the  face  and  trunk. 

It  is  a  disease  of  childhood  as  a  rule,  but  is  also  met  with 
sometimes  during  lactation. 

It  is  most  often  associated  with  chronic  dilatation  of  the 
stomach  or  intestine,  but  it  may  follow  removal  of  the 
thyroid  gland.  In  the  latter  case  the  parathyroids  are 
supposed  to  be  at  fault,  as  excision  of  the  parathyroids  in 
certain  animals  may  induce  tetany. 

The  actual  spasms  are  preceded  by  numbness  and  tinglmg 
in  the  hands  and  feet. 

During  the  tonic  spasms  the  fingers  are  flexed  at  the 
metacarpo-phalangeal  joints  and  extended  at  the  inter- 
phalangeal  joints  ;  the  thumb  is  adducted  and  its  tip  meets 
the  finger  tips.  The  wrist  is  flexed,  the  forearm  pronated 
and  adducted,  and  the  elbows  flexed.  The  feet  are  arched 
and  inverted  ;  the  legs  are  extended  and  adducted. 

The  spasms  start  suddenly  and  relax  gradually  after  some 
minutes  or  possibly  not  for  many  hours. 

The  following  signs  may  be  mentioned  : — 

(i.)  Trousseau  s  Sign.  Compression  of  the  blood-vessels 
to  a  limb  may  induce  an  attack. 

(ii.)  Chvostek's  Sign.  Tapping  on  the  facial  nerve  may 
induce  a  spasm  of  the  facial  muscles. 

The  typical  carpo-pedal  spasm  is  not  simulated  by  any 
other  condition. 

In  tetanus  there  is  a  history  of  some  lesion  and  the  earliest 


DISORDERS   OF   MOTION  673 

signs  are  in  the  neck  and  jaw  muscles.  Trismus  never 
occurs  in  tetany. 

IV.  Occupation  Neuroses.  The  oft -repeated  performance 
of  the  same  actions,  especially  actions  involving  the  small 
muscles  of  the  hand,  sometimes  induces  cramp-like  contrac- 
tions in  these  muscles,  which  may  be  so  severe  as  to  prevent 
the  further  performance  of  the  specific  acts. 

These  conditions  are  not  to  be  regarded  as  due  to  any 
organic  lesion  and  are  always  associated  with  general 
symptoms  of  neurasthenia.  Tremor  of  the  hand  is  a  constant 
accompaniment. 

They  must  not  be  confounded  with  craft  palsies  (vide 
infra). 

The  following  examples  of  occupation  neurosis  may  be 
mentioned  : —  / 

(i.)  Writer's  cramp.  This  affects  the  flexors  of  the  thumb 
and  first  fingers,  but  may  involve  the  MTist  and  forearm, 
^luch  writing  may  induce  a  temporary  "  fatigue  cramp  " 
in  anybody,  but  this  passes  off  with  a  little  rest,  whereas 
in  true  ^^Titer"s  cramp  the  spasms  start  again  as  soon  as 
^\Titing  is  once  more  attempted,  even  after  prolonged  rest. 

(ii.)  Tailors  and  sempstresses  may  have  very  similar 
affections. 

(iii.)  PianistSf  telegraphists ^  and  stenographers  are  liable 
to  cramps  in  the  extensors  of  the  wTists,  violinists  in  the 
thumb  and  finger  muscles  of  the  left  hand. 

(iv.)  Hanimermen  may  suffer  from  analogous  cramps  in 
the  deltoid  and  triceps  muscles. 

Craft  Palsies  arc  due  to  a  true  pressure  neuritis,  the  result 
of  long-continued  over-exertion  of  certain  muscles  or  muscle 
groups,  especially  in  the  case  of  the  small  muscles  of  the 
hands. 

Muscular  atrophy  as  well  as  the  subjective  sensory 
changes  of  true  neuritis  are  present. 

JMaters.  locksmiths,  and  cigar  or  cigarette  rollers  are 
])erhaps  most  frequently  affected. 


CHAPTER   XII 
CERTAIN    FUNCTIONAL    DISEASES 

A.  Epilepsy. 

Epilepsy  is  a  chronic  progressive  disease  characterised 
by  recurrent  seizures,  always  associated  with  impairment  of 
consciousness  and  very  often  with  convulsions.  Progressive 
mental  deterioration  is  common. 

There  is  a  definite  hereditary  factor  in  epilepsy,  about 
half  the  cases  giving  a  family  history  of  epilepsy,  insanity, 
or  alcoholism.  Males  are  more  often  affected  than  females. 
The  majority  of  cases  seem  to  start  either  in  the  first  eight 
or  nine  years  of  life  or  between  the  ages  of  14  and  21  years, 
but  no  age  is  immune. 

The  pathology  of  epilepsy  is  not  understood. 

For  convenience  in  description  Jacksonian  or  focal 
ej)ilepsy  is  included  under  the  heading  "  Epilepsy,"  but  it 
must  clearly  be  understood  that  Jacksonian  epilepsy  is 
produced  by  some  definite  and  organic  intra-cranial  lesion, 
whereas  in  idiopathic  epilepsy  no  such  condition  can  be 
demonstrated. 

Clinically  Epilepsy  may  be  considered  under  five  headings  : 
(i.)  Jacksonian  or  Focal  Epilepsy, 
(ii.)  Major  EpUepsy  [Grand  Mai). 
(iii.)  Minor  Epilepsy  {Petit  Mai). 
(iv.)  (Status  Epilepticus. 
(v.)  Psychical  Epileptic  Phenomena. 

I.  Jacksonian  Epilepsy.  Any  organic  lesion  which  involves 
the  cerebral  cortex  either  directly  or  indirectly  is  likely 
to  be  accompanied  by  convulsive  attacks  which  correspond 
in  their  nature  and  distribution  to  the  affected  part  of  the 
brain.  The  more  strictly  cortical  is  the  lesion,  the  more 
localised  are  the  convulsions. 

The  following  are  the  characteristic  features  of  Jacksonian 
epilepsy  : — 


CERTAIN   FUNCTIONAL   DISEASES  575 

(a)  The  attacks  always  start  in  the  same  manner  and 
m  the  same  part  of  the  body. 

(6)  If  the  attacks  become  generalised,  the  order  of 
progression  is  constant. 

(c)  There  is  no  loss  of  consciousness  unless  the  attacks 
become  generalised. 

//  the  lesion  is  in  the  motor  area  there  are  clonic  contrac  - 
tions  of  the  corresponding  muscle  groups  on  the  opposite 
side  of  the  body.  In  severe  cases  atonic  stage  maybe  ap- 
parent. The  convulsions  may  be  limited  to  a  certain  area 
{e.g.,  arm  and  face),  or  they  may  spread  till  a  considerably 
wider  region  or  even  the  whole  body  becomes  mvolved. 

//  the  lesion  is  in  the  sensory  area  the  first  signs  of  an  attack 
are  parsesthetic  sensations  in  a  particular  locality  ;  these 
sensory  phenomena  are  generally,  but  not  always,  follcfwed 
by  convulsions  in  the  corresponding  motor  area. 

//  the  lesion  is  in  the  psijchical  area  the  earliest  and  ofteii 
the  only  sign  is  a  transient  loss  of  consciousness  strictly 
comparable  to  petit  mat. 

II.  Major  Epilepsy.  The  majority  of  attacks  are  preceded 
by  a  sensory  or  psychical  warning  which  is  called  an  "  aura." 

The  following  are  the  most  common  varieties  of  aura  : — 
(a)  Abnormal  sensation  in  the  epigastrium  or  tliorax, 

such  as  cramps,  spasms  or  feelings  as  of  suffocation. 
(6)  CHirious  sensation  in  the  head. 
(r)  Subjective  sensations  of  the  special  senses,  visual, 

olfactory,  or  gustatory. 

(d)  Psychical  phenomena,  such  as  sensations  of  dread 
or  of  fear,  or  dreamy  conditions. 

(e)  Sensory  phenomena  of  all  sorts  affecting  any  part 
of  the  limbs,  trunk,  or  head. 

After  the  aura  has  developed,  if  one  be  present,  the  patient 
utters  a  cry,  loses  consciousness,  and  falls  to  the  ground 
m  a  state  of  general  tonic  muscular  spasm.  He  does  not 
hear  the  cry  he  utters.  His  arms  are  abducted  and  flexed 
at  the  elbows  ;  his  legs  are  extended  and  inverted.  His 
head  and  eyes  show  conjugate  deviation  ;  the  pupils  are 
fixed  and  dihited.  He  becomes  increasingly  cyanosed, 
since  respiration  has  ceased.  After  a  time,  varying  from  a 
few  seconds  to  a  minute  and  a  half,  the   tonic  stage  gives 


576  MEDICAL   DIAGNOSIS 

way  to  iJie  clonic  stage  and  respiration  is  re-established. 
This  stage  lasts  perhaps  for  three  or  four  minutes,  and  as 
it  wears  off  the  patient  passes  into  a  condition  of  stupor 
which  generally  merges  into  deep  sleep.  The  deep  reflexes 
are  usually  increased  for  a  short  time  after  a  fit.  The 
patient  may  suffer  considerable  injury  from  his  fall  and 
he  may  bite  his  tongue  or  cheeks  during  the  fit  ;  or  he  may 
suffocate  himself  by  falling  face  downwards  on  a  pillow  or 
into  a  pool  oi  water.  He  not  infrequently  passes  both 
water  and  faeces  while  unconscious. 

The  fits  may  occur  many  times  daily,  or  they  may  be 
separated  from  each  other  by  many  months  ;  sometimes 
the  fits  only  happen  at  night  (nocturnal  epilepsy).  In  this 
form  the  patient  may  die  of  suffocation,  owing  to  the  fact 
that  the  fit  leaves  him  in  such  a  position  that  he  cannot 
breathe. 

III.  Minor  Epilepsy.  Two  forms  of  minor  epilepsy  can 
be  recognised — first,  where  a  characteristic  "  aura  "  is 
experienced  but  where  no  further  manifestation  in  the  direc- 
tion of  convulsions  or  unconsciousness  occurs,  and,  secondly, 
where  there  is  no  aura  but  where  there  are  recurrent  attacks 
of  what  is  described  as  "  fainting,"  "  loss  of  memory," 
"  falling  over  "  with  or  without  a  cry,  etc.,  etc. 

All  these  phenomena  are  very  brief,  but  it  is  of  especial 
importance  that  their  true  significance  should  be  recognised, 
as  they  respond  not  infrequently  to  treatment. 

The  post-epileptic  phenomenon  of  "  automatism  "  is  par- 
ticularly likely  to  follow  this  latter  variety  of  minor  epilepsy, 

IV.  Status  Epilepticus.  This  maysupervene  in  any  variety 
of  epilepsy,  and  sometimes  it  develops  if  bromides  are  left 
off  too  euddenly.  The  fits  follow  each  other  practically 
without  cessation  and  with  little  or  no  interval  of  conscious- 
ness. 

If  the  fits  do  not  stop  the  temperature  rises  and  death 
takes  place  in  about  forty-eight  hours  as  a  rule. 

V.  Psychical  Epileptic  Phenomena.  It  sometimes  happens 
that  epileptics  are  men  of  undoubted  genius  ;  more  often 
there  is  obvious  mental  impairment  with  defective  judgment, 
imperfect  memory,  and  religious  enthusiasm,  which  does  not 
coincide  with  their  daily  life. 


CERTAIN   FUNCTIONAL   DISEASES  577 

Many  patients  show  progi'essive  dementia  and  eventually 
become  hopelessly  imbecile. 

Psychical  phenomena  occurring  before  a  paroxysm  should 
be  regarded  as  part  of  an  "  aura  ''  which  is  unduly  prolonged. 
Psychical  phenomena  occurring  after  a  paroxysm  may  take 
the  following  forms  : — 

(i.)  Acute  Dementia.  This  sometimes  develops  when  there 
have  been  an  unusual  number  of  fits  in  a  short  time  ;  it  is  a 
temporary  condition. 

(ii.)  Acute  Mania.  This  is  rare  and  generally  lasts  for 
ten  or  twelve  hours. 

(iii.)  Delusions.  A  fit  or  series  of  fits  may  sometimes  be 
followed  by  a  definitely  delusional  state  which  may  last 
several  days. 

(iv.)  Automatistii.  This  is  most  noticeable  after  mduor 
attacks  ;  any  form  of  automatic  action  may  be  performed. 
The  duration  of  the  automatic  stage  is  doubtful,  and  many 
crimes  have  been  attributed  to  post-epileptic  automatism 
which  were  probably  not  due  to  this  at  all. 

Psychical  Ejnleptic  Equivalents.  It  is  possible  that 
psychic  phenomena  may  replace  the  more  usual  motor 
signs  in  certain  cases  of  epilepsy,  though  how  far  such 
equivalents  differ  from  automatism  and  other  psychic 
manifestations  of  minor  epilepsy  seems  doubtful. 

The  diagno.sis  of  Epilepsy  is  not  always  easy.  It  is 
important  to  remember  that  tyj)ical  attacks  of  grand  mal 
may  be  produced  by  gross  intra-cranial  disease,  and  such 
diseases  as  cerebral  tumour  nuist  always  be  excluded  before 
diagnosing  epilepsy  [mde.  p.  ")23).  In  like  mainior  ura-mic 
fits  should  be  eliminated. 

Major  Epilepsy,  especially  if  th(^  attacks  are  not  seen  by 
the  physician,  may  present  some  resemblance  to  hysteria. 
The  following  table  based  on  that  drawn  up  by  Sir  William 
Gowers  presents  the  chief  differential  points  :■ — 


Epilepsy* 

Hysteria, 

Apparent 

cause. 

Nona 

Emotion. 

W'a  mi  Hff. 

Especially  one  of  the 

Palpitation,      malaise. 

aursD     d  e  s  c  r  i  1)  0  d 

chokinfj,  druniminfj;  on 

above. 

the  floor  with  the  feet. 

Ovset. 

Always  sudden. 

Often  trrndual. 

M.D. 

37 

578 


MEDICAL   DIAGNOSIS 


Epilepsy. 

Hysteria. 

Scream. 

At  onset. 

During  course. 

Convulsions. 

Tonic,  then  clonic. 

Kigidity,         struggling, 

arching  of  back. 

Micturition. 

Frequent. 

Never. 

Duration. 

Three  to  four  minutes. 

Ten   minutes   or   longer. 

Restraint  neces- 

To    prevent 

patient 

To  prevent  patient  hurt- 

sary. 

being  hurt. 

ing  other  people. 

Termination. 

Spontaneous. 

Can   be  induced   (as   by 
slapping  the  face,  pull- 
ing the  hair,  drenching 
with    cold    water,    or 
applying       a       strong 
faradic  current). 

Nocturnal  epilepsy  may  escape  recognition  for  a  long 
time,  but  suspicion  should  be  aroused  if  a  patient  complains 
of  waking  with  a  sense  of  muscular  fatigue,  a  sore  tongue,  a 
wet  bed,  or  blood  on  the  pillow. 

Minor  epilepsy  is  often  overlooked  in  childhood  ;  it  should 
be  remembered  that  it  is  probably  the  most  frequent  cause 
of  repeated  so-called  "  fainting  "  attacks  in  young  children, 
though  similar  phenomena  may  be  produced  by  intestinal 
parasites,  especially  round  worms.  Cardiac  lesions  are  an 
extremely  rare  cause  of  fainting  in  childhood. 

A  patient  with  sufficient  cardiac  damage  to  account  for 
syncope  may  also  be  a  minor  epileptic  ;  the  epileptic  attacks, 
however,  are  attended  by  complete  and  sudden  loss  of 
consciousness  and  are  followed  by  some  automatism.  The 
pulse  is  not  affected,  whereas  in  true  syncopal  attacks  the 
loss  of  consciousness  is  gradual,  there  is  marked  pallor,  and 
the  pulse  becomes  distinctly  feeble. 

In  conclusion  we  would  emphasise  the  fact  that  it  is 
scarcely  justifiable  to  diagnose  epilepsy  without  there  being 
at  some  time  (not  necessarily  with  every  seizure)  some  loss 
or  impairment  of  consciousness.  Apart  from  this  perhaps 
the  most  conclusive  signs  are  a  fall,  tonic  spasms  followed  by 
clonic,  involuntary  micturition,  and  biting  of  the  tongue. 

B.  Migraine  (Periodic  Headache). 

It  seems  unnecessary  to  distinguish  between  cases  present- 
ing all  the  classical  phenomena  of  migraine  and  those  in 


CERTAIN   FUNrTTOXAL   DISEASES  579 

which  a  periodic  headache,  with  no  discoverable  cause,  is 
the  only  feature. 

Periodic  headaches  are  more  frequent  in  women  than  in 
men  ;  they  usually  commence  in  childhood  and  tend  to 
diminish  or  cease  after  the  climacteric.  There  is  a  strong 
hereditary  influence  in  most  cases. 

The  pathology  of  these  headaches  is  not  understood  but 
there  seems  to  be  a  relationship  between  migi'aine  and 
epilepsy  ;  the  children  of  epileptics  may  have  migraine,  and 
attacks  of  migraine  may  be  replaced  by  epileptic  fits. 

Symptoms.  The  most  constant  feature  is  headache  ; 
this  is  often  unilateral,  but  varies  in  position  with  different 
cases  ;  the  frontal  region  is  most  often  affected.  The  pain 
may  be  either  boring,  piei'cing,  or  throbbing  in  character. 

The  most  typical  cases  have  a  definite  "  aura,"'  -v^hich 
precedes  the  headache  by  a  short  time. 

The  usual  aura  is  visual  in  nature  and  may  consist  of 
flashes  of  light,  sparks  of  light,  zig-zag  streaks  of  light 
(teichopsia),  a  central  bright  spot  or  a  central  dark  spot 
(scotoma)  which  extends  to  the  periphery  of  the  visual  fiekl, 
but  as  it  spreads  clears  up  in  the  centre.  Homonymous 
hemianopia  is  another  common  visual  aura. 

Less  common  warnings  are  feelings  of  numbness  or  ting- 
ling referred  to  the  arms,  face,  tongue  and  lips,  and  occa- 
sionally paraphasia  (use  of  the  wrong  word  or  inability  to 
find  the  word  wanted). 

The  average  duration  of  the  warnmg  symptoms  is  twenty 
minutes  and  as  they  pass  away  the  headache  develops. 
The  pain  lasts  for  twelve  to  twenty-four  houis.  and  in  most 
cases  terminates  by  vomiting  or  nausea  ;  in  other  cases  the 
vomiting  may  be  present  all  through  the  period  of  headache. 

It  must  be  understood  that  the  course  of  events  differs 
greatly  in  different  cases,  but  tends  to  follow  the  same 
general  sequence  for  the  same  patient. 

The  individual  attacks  may  be  precipitated  by  certain 
factors  which  vary  in  different  cases  ;  the  tendency  for  the 
menstrual  period  to  be  accompanied  by  this  type  of  headache 
is  well  kiKnvn. 

Other  common  exciting  causes  arc  digestive  disturbances, 
overwork,  over-worry,  over-fatigue  and  over-excitement. 

'M  —3 


580  MEDICAL   DIAGNOSIS 

Persons  who  are  "  run-down  "  or  "  anpemic  "  are  more 
liable  to  migrainous  attacks,  as  are  those  with  naso -pharyn- 
geal bbstruction  or  refractive  errors,  especially  the  lesser 
degrees  of  astigmatism. 

The  diagnosis  of  migraine  rests  upon  the  character  of  the 
attacks  and  the  exclusion  of  gross  organic  disease  (cerebral 
tumour  or  nephritis)  and  of  any  remediable  reflex  cause 
(refractive  error  or  adenoids).  The  diagnosis  is  strengthened 
if  the  attacks  started  in  childhood  or  adolescence  and  if  the 
patient  is  a  female. 

C.  The  Tics,  or  Habit  Spasms. 

A  habit  spasm  is  the  involuntary  and  automatic  perform- 
ance of  a  co-ordinated  purposive  act.  In  addition  to  these, 
psychical  tics  are  met  with  in  which  the  subject  is  compelled 
to  perform  certain  acts  in  a  special  manner  or  to  precede 
certain  actions  by  the  utterance  of  certain  words  or 
numbers. 

Ordinary  habit  spasms  often  start  in  adolescence,  and  not 
infrequently  develop  from  repeated  voluntary  performance 
of  certain  acts  ;  for  example,  a  boy  who  kept  rabbits 
imitated  the  wriggling  movements  of  their  noses  and  upper 
lips  until  he  acquired  this  action  as  a  tic. 

The  following  common  forms  of  Motor  Tic  may  be  men- 
tioned : 

I.  Facial  Tics.  Blinking,  winking,  smacking  the  lips, 
"  pulling  faces,"  smiling,  etc. 

II.  Neck  Tics.  Tossing  and  nodding  the  head  and 
spasmodic  torticollis,  which  is  one  of  the  most  common 
forms  of  tic.     The  essential  features  of  torticollis  are  : 

(a)  The   movement   is   one   which   can  be   performed 
voluntarily. 

(6)  The  movement  can  be  controlled  in  the  early  stages, 
(c)  There    is,    in    the    fully-developed    condition,    an 
uncontrollable  impulse  for  the  performance  of  the  move- 
ment. 

Many  patients  with  torticollis  habitually  control  the 
spasmodic  movements  by  carrying  one  or  two  fingers  in 
apposition  to  their  chins  ;  as  soon  as  the  hand  is  removed  the 


CERTAIN   FUNCTIONAL  DISEASES  581 

spasms  take  place,  and  yet  the  hand  is  in  no  way  used  for 
holding  the  head  steady. 

III.  Arm  Tics.  Shi'ugging  the  shoulders  and  abducting 
or  adducting  the  arms. 

IV.  Leg  Tics.  Many  unusual  gaits  are  of  the  nature  of  a 
tic. 

V.  Speech  Tics.  The  uncontrollable  emission  of  words  or 
phrases  which  have  no  logical  bearmg  on  the  environment. 

VI.  Convulsive  Tics.  This  rare  condition  is  characterised 
by  three  phenomena  : — 

(a)  Spasmodic  jerking  movement. 

(6)  Emission  of  irrelevant  words  or  phrases  (frequently 
obscene  or  blasphemous). 

(c)  Obsessive  ideas  which  lead  to  all  sorts  of  foolish  or 
dangerous  acts. 

Diagnosis.  The  most  important  diagnostic  features  of  the 
tics  are  : — • 

(i.)     The  fact  that  the  movements  can  be  controlled 

voluntarily  to  some  extent  and  that  the  exercise  of  such 

control  causes  definite  mental  distress. 

(ii.)  The   movements   are  notably  lessened   when   the 

patient's  attention  and  interest  are  fully  occupied. 

(iii.)  Psychical  instability,  or  at  least  a  history  of  such 

in  the  family — for  example,  insanity,  alcoholism,  epilepsy, 

chorea. 

(iv.)  The  movements  cease  during  sleep. 

It  is  quite  possible  to  mistake  some  forms  of  habit  spasm 
for  chorea  {inde\).  571)  if  the  first  two  of  the  above  charac- 
teristics are  not  borne  in  mind. 

In  paramyoclonus  multiplex  the  movements  are  mostly 
of  certain  of  the  leg  muscles  ;  they  are  bilateral,  they  are  not 
purposive  acts,  and  they  are  absolutely  uncontrollable  by 
will. 


CHAPTER  XIII 
VASO  MOTOR  AND  TROPHIC  DISEASES 

I.  Raynaud's  Disease.  This  is  more  common  in  women 
than  men  ;  it  may  be  induced  by  cold  or  by  shock,  and 
appears  to  depend  upon  a  vaso-motor  disturbance  which 
produces  a  spasm  in  the  arteries  of  the  extremities. 

The  disease  is  nearly  always  bilateral  and  in  addition  to 
the  hands  and  feet  the  nose  and  ears  may  be  affected. 

Clmically  three  stages  may  be  recognised  : — 

(i.)  Local  Syncope.  A  numbness  and  feeling  of  deadness 
in  the  fingers,  accompanied  by  pallor  and  anaemia  and 
obvious  coldness.  After  a  period  of  mmutes  or  hours  the 
arteries  relax  and  the  ordinary  appearances  and  sensations 
are  restored. 

(ii.)  Local  Asphyxia.  This  may  follow  the  local  syncope 
or  may  be  a  primary  stage.  A  temporary  blanchmg  is 
followed  by  extreme  congestion  with  marked  discoloration 
of  the  parts,  which  become  purple  and  show  distended  veins. 
The  hands  and  feet  are  usuallj^  affected.  The  similarity 
to  chilblains  is  striking. 

After  a  matter  of  hours  or  days  these  phenomena  tend  to 
subside  or  may  proceed  to  the  third  stage. 

(iii.)  Local  Gangrene.  If  recovery  does  not  follow  the 
asphyxial  or  even  the  syncopal  stages  localised  dry  gangrene 
ensues.  The  gangrenous  patches  may  be  very  small  or  may 
mvolve  whole  fingers,  though  as  a  rule  the  bone  escapes. 

An  essential  feature  of  Raynaud's  disease  is  the  paroxysmal 
nature  of  the  manifestations,  which  serves  to  exclude  such 
conditions  as  senile  gangrene  or  congenital  heart  disease. 

Some  cases  of  Raynaud's  disease  show  the  very  interesting 
complication  of  paroxysmal  hsemoglobmuria  ;  in  others 
recurrent  paralyses,  presumably  due  to  temporary  ischsemia 
in  the  cerebral  vessels,  have  been  described. 

II.  Intermittent  Claudication  (Limping).     This  rare  con- 


VASO-MOTOR   AND   TROPHIC   DISEASES        583 

dition  usually  develops  during  muscular  exercise  and  is 
dependent  upon  the  temporary  withdrawal  of  blood  from 
certain  leg  muscles  owing  to  spasm  of  the  arteries. 

During  the  attack  no  pulse  can  be  felt  in  the  dorsalis 
pedis  or  posterior  tibial  arteries  and  the  limb  becomes 
cold. 

The  condition  is  usually  unilateral  and  tends  to  be  pro- 
gressive. During  the  attacks  there  are  cramps  in  the 
muscles,  and  the  leg  feels  as  if  it  were  going  to  burst  ;  it 
may  be  swollen  and  discoloured. 

III.  Erythromelalgia.  A  rare  chronic  disease  affecting 
women  more  than  men,  and  mostly  seen  in  the  Jewish  race. 
It  is  characterised  by  severe  local  pain  with  redness, 
swelling,  and  increased  temperature,  usually  in  one  or  other 
foot.  '        / 

The  pathology  is  thought  to  be  a  combmation  of  vaso- 
motor derangement  with  diseased  blood-vessels,  and  possibly 
peripheral  nerve  degeneration  also. 

IV.  Angioneurotic  (Edema.  This  condition  results  from 
vaso-motor  disturbance  and  manifests  itself  by  the  occur- 
rence of  local  cedematous  patches,  which  are  definitely  cu'- 
cumscribed  but  which  may  involve  the  mucous  membranes 
equally  with  the  skin. 

The  appearance  of  the  patches  may  be  strikingly  periodic, 
and  each  patch  is  often  very  brawny  in  consistence. 

If  the  larynx  is  involved,  tracheotomy  may  be  necessary. 
If  the  stomach  or  intestines  are  affected,  disturbance  of 
their  functions  may  be  a  feature  of  the  case. 

V.  Facial  Hemiatrophy.  This  rare  disease  nearly  always 
starts  in  childhood  and  shows  itself  by  a  progressive  wasting 
of  all  the  tissues  of  one  half  of  the  face. 

The  cause  is  believed  to  be  due  to  an  interstitial  neuritis 
of  the  fifth  nerve,  but  as  there  is  no  sensory  disturbance 
it  is  hard  to  believe  that  this  is  the  only  factor. 

VI.  Scleroderma.  This  chronic  condition  js  characterised 
l)y  a  local  or  diffuse  induration  of  the  skin.  In  the  affected 
areas  the  secretion  of  sweat  is  abolished,  so  that  the  skin 
a])p('ais  smooth,  dry,  and  glossy. 

( )c{;asionally  Raynaud's  di.stMse  and  scleroderma  are 
associated. 


584  MEDICAL   DIAGNOSIS 

When  the  fingers  are  especially  affected  (sclerodactylie) 
they  may  become  notably  pointed,  deformed,  atrophied, 
and  shortened  ;    the  nails  may  completely  disappear. 

Scleroderma  is  regarded  as  a  tropho-neurosis,  a  view  which, 
however,  does  little  to  explain  satisfactorily  its  pathology. 


CHAPTER   XIV 
HYSTERIA  AND  NEURASTHENIA 

Hysteria  is  a  psychical  disorder  whereby,  according  to 
Janet,  there  is  a  dissociation  of  certain  mental  processes 
from  the  maiii  consciousness.  It  is  most  common  in  the 
female  sex  and  is  most  frequently  seen  in  adolescence  ; 
it  may  be  started  by  trauma,  shock,  or  prolonged  strain  or 
ill-health.  Hysterical  persons  are  unduly  susceptible  to 
impressions  from  without,  whether  psychical  or  physical. 

The  manifestations  of  hysteria  are  extremely  diverse  ; 
the  following  are  some  of  the  more  important  : — 

I.  Hysterical  Seizures,  (a)  Mmor  AttacJcs.  These  are 
likely  to  follow  some  form  of  emotional  disturbance,  and 
consist  of  such  phenomena  as  palpitations,  a  lump  rising 
from  the  stomach  to  the  throat,  and  feelings  of  suffocation. 
The*  patient  gets  excited  and  fights  for  breath  and  finally 
bursts  into  tears  or  laughter,  or  even  "  famts."  The  attack 
may  terminate  in  eructations  or  with  passage  of  large 
quantities  of  urine. 

(h)  Major  Attack-^.  These  usually  develop  from  some 
form  of  minor  attack  as  described  above  ;  es^entually  the 
patient  reaches  the  ground,  sometimes  she  reaUy  seems  to 
fall  suddenly,  but  more  often  she  subsides  gradually  : 
she  may  appear  to  be  unconscious.  She  often  assumes  a 
crucifixion  attitude  with  arms  and  legs  outstretched  ;  she 
becomes  rigid  and  exhibits  convulsive  movements  (bilateral), 
and  often  shows  opisthotonos.  The  eyelids  are  often 
tightly  shut  and  the  globes  turned  upwards  and  inwards. 
These  performances  frequently  continue  for  several  Iioiiis  : 
they  rarely  last  for  less  than  fifteen  minutes. 

There  is  no  mental  disorder  or  automatism  after  tiie 
attacks  and  their  termination  is  quite  abrupt,  but  the  pat  icnt . 
as  a  lulc,  has  little  or  no  knowledge  of  what  has  ha})})oiK'd 
(luiinu  till'  "  lit." 


58G  MEDICAL   DIAGNOSIS 

The  diagnosis  from  epilepsy  has  been  described  (p.  577). 

(c)  Hystero-Ejpilepstj  of  French  writers.  This  is  possibly 
an  exaggeration  of  the  major  attacks.  Real  unconsciousness 
may  develop,  but  throughout  the  attack  the  movements 
appear  to  be  dominated  by  some  definite  subconscious 
idea.  After  the  attack  there  may  be  hallucinations, 
contractures,  paralyses,  or  even  delirium. 

(f?)  Catalepsy.  This  consists  of  profound  sleep,  in  which 
the  limbs  assume  a  plastic  rigidity  and  remain  as  they  are 
put.  The  breathing  is  superficial  and  the  surface  tempera- 
ture subnormal. 

II.  Hysterical  Affections  of  the  Cranial  Nerves,  (a)  Smell 
and  taste  may  be  abolished. 

(6)  Concentric  contraction  of  the  visual  fields,  either 
bilateral  or  unilateral.  The  disturbance  may  be  for  all 
forms  of  vision  or  chiefly  for  colour  vision,  in  which  case  the 
red  field  is  conspicuously  well  preserved,  whereas  in  organic 
lesions  the  red  and  green  fields  are  affected  early. 

(c)  Deafness  similar  to  cortical  deafness  is  fairly  common. 

{d)  Anaesthesia  of  the  face,  if  hysterical,  includes  the 
lower  jaw,  which  is  really  supplied  by  the  cervical 
nerves. 

(e)  Spasms  of  the  face  muscles  and  the  tongue  are  usually 
hysterical. 

(/)  In  hysterical  aphonia  the  patient  can  barely  whisper. 
The  cords  are  in  the  abducted  position. 

III.  Motor  Signs  of  Hysteria,  (a)  Flaccid  Paralysis.  This 
is  nearly  always  accompanied  by  complete  anaesthesia  of  the 
affected  part  or  of  half  the  body.  A  limb  may  be  affected 
or  there  may  be  paraplegia  or  hemiplegia.  There  may  be 
general  wasting,  but  there  is  no  reaction  of  degeneration,  no 
hypotonia,  and  the  reflexes  are  present — indeed,  they  are 
often  brisk. 

If,  in  hysterical  hemiplegia,  the  patient  is  told  to  sit  up  in 
bed  the  paralysed  leg  remains  quite  flat  on  the  bed.  In 
organic  hemiplegia  under  like  circumstances  the  paralysed 
leg  is  lifted  higher  off  the  bed  than  the  sound  one,  as  the 
abdommal  muscles  contract. 

(6)  Paralysis  with  Stiffness.  There  is  usually  some  power 
of   movement  and    the  stiffness  does  not  amount  to  true 


HYSTERIA   AND   XEURASTHEXIA  587 

spasticity.  The  performance  of  a  voluntary  movement  is 
attended  by  great  apparent  effort. 

A  feature  of  these  cases  is  that  when  the  affected  limb 
is  voluntarily  moved  in  a  specific  manner  the  opposing 
muscles  undergo  a  slight  contraction  before  the  muscles 
concerned  in  the  main  movement  commence  to  contract. 
This  does  not  happen  in  organic  paralj^sis. 

If  the  legs  are  affected  the  gait  is  shuffling,  but  does  not 
resemble  the  gait  of  a  similar  organic  lesion  ;  commonly 
the  toes  are  pointed  and  the  dorsum  of  the  foot  rests  on 
the  floor. 

(c)  Hysterical  Contractures  are  due  to  strong  muscular 
contractions  ;  their  nature  can  be  diagnosed  by  the  fact 
that  they  disappear  spontaneously  under  an  anaesthetic, 
which  does  not  happen  to  organic  contractures.  / 

{d)  Hysterical  Tremors.  Almost  any  form  of  tremor 
may  be  a  manifestation  of  hysteria. 

IV.  Sensory  Manifestations  of  Hysteria,  {a)  Subjective. 
Pain  and  hj-pera-'sthesia  may  be  complamed  of,  especially 
in  the  head,  back,  side  of  the  chest  and  left  breast. 

Local  tenderness  to  pressure  is  peculiarly  well  marked. 

The  clavus  hystericus  (a  feeling  as  of  a  nail  being  driven 
into  the  vertex  of  the  skull)  is  a  common  manifestation  of 
hysteria. 

{b)  Objective.  Anaesthesia  is  one  of  the  most  common 
jjlionomena  in  hysteria  ;  it  may  be  the  only  manifestation 
or  may  accompany  any  of  the  other  signs.  It  is  commonly 
not  known  to  the  patient  till  her  attention  is  drawn  to  it. 

Tlie  site  of  the  anaesthesia  is  not  constant  ;  it  shifts 
from  day  to  day  or  even  from  hour  to  hour. 

The  loss  of  sensation  may  be  partial  or  complete  ;  often 
the  loss  is  confined  to  the  cutaneous  sensibilities.  The 
distribution  is  rarely  in  conformity  with  any  possible 
nervous  distribution,  either  .segmental  or  peripheral. 

There  is  nearly  always  a  definite  circular  upper  limit  if 
a  limb  is  concerned,  and  in  the  case  of  the  trunk  the  loss 
often  ceases  absolutely  at  the  mid-line. 

llcmiana'sthesia  is  conmion,  as  is  a  quacU'antic  distribu- 
tion— for  e.xample,  the  left  arm  and  the  right  leg. 

\'.  The  Reflexes  in  Hysteria.     The  deep  reflexes  are  usually 


588  MEDICAL   DIAGNOSIS 

brisk.  They  are  never  abolished.  A  pseudo -clonus  may 
be  elicited,  but  not  when  there  is  any  rigidity.  The  abdominal 
reflexes  are  not  lost,  though  if  there  is  abdominal  anaesthesia 
it  may  be  very  difficult  to  obtain  them.  There  is  never  a 
plantar  reflex  of  extensor  type. 

There  is  never  any  further  sphincter  trouble  than  retention 
of  urine. 

VI.  Special  Manifestations  of  Hysteria,  {a)  Anorexia 
Nervosa.  This  condition  has  been  described  on  p.  350. 
It  may  occur  alone  ar  with  other  definite  stigmata  of 
hysteria.  The  chief  feature  is  a  persistent  refusal  of  food, 
often  accompanied  by  prompt  regurgitation,  or  vomiting,  of 
any  that  may  be  taken.  Emaciation  is  profound  and 
death  from  starvation  may  occur. 

The  onset  of  such  symptoms  during  puberty  should  excite 
suspicion  of  a  functional  cause.  This  is  confirmed  by 
the  absence  of  any  oesophageal  obstruction  or  other  evi- 
dence of  organic  disease  {vide  also  "  Oesophageal  Spasm," 
p.  321). 

(b)  Hysterical  vomiting  without  anorexia  is  not  uncommon  ; 
a  feature  of  this  is  the  absence  of  nausea  or  pam  and  also 
the  fact  that  in  many  cases  there  is  little  or  no  loss  of  flesh. 
Organic  cerebral  disease  must  be  excluded. 

(c)  Air-swallowing  ivith  subsequent  eructations  is  a  common 
manifestation  of  hysteria  ;    the  diagnosis  is  self-evident. 

(d)  Hysterical  Spine.  Pam  in  the  spine  (usually  the 
lower  part),  with  tenderness  on  pressure,  may  be  hysterical. 
There  is  no  curvature  except  possibly  a  lateral  scoliosis  from 
muscular  weakness,  which  immediately  disappears  on 
bending  down.  The  tenderness  is  usually  as  well  marked 
on  light  pressure  as  on  deep,  and  is  not  sharply  localised. 

These  pomts  and  the  absence  of  any  root  symptoms  may 
serve  to  distinguish  tuberculous  disease  and  also  malignant 
disease,  which  is  unusual  before  the  age  of  40  years. 

(e)  Hysterical  Joints.  Tuberculous  joints  (especially  the 
hip  jomt)  may  be  closely  simulated.  There  is,  however, 
never  real  shortening,  and  an  X-ray  examination  would  put 
the  matter  beyond  question. 

In  conclusion  it  may  be  stated  that  a  diagnosis  of  hysteria 
is  only  justifiable  when  every  means  has  been  taken  to  exclude 


HYSTERIA   AND    NEURASTHENIA  589 

organic  disease  and  after  a  very  comprehensive  review  of 
the  case  as  a  whole. 

It  must  never  be  forgotten  that  many  cases  of  organic 
disease  may  show  hj'sterical  signs  also,  and  that  the  first 
signs  of  organic  lesions  may  be  indistinguishable  from 
hysteria. 

The  special  points  in  diagnosis  between  hysteria  and 
epilepsy  and  disseminated  sclerosis,  have  been  mentioned 
under  the  headings  of  these  latter  diseases. 

NEURASTHENIA. 

Neurasthenia  is  a  condition  of  fatigue  both  mental  and 
})hysical,  generally  accompanied  by  paui  and  other  sub- 
jective sensory  phenomena,  but  not  by  any  evidence  of 
organic  disease  of  the  central  nervous  system.  ' 

The  most  common  age  for  neurasthenia  is  30  to  50  years. 
Men  suffer  more  often  than  women,  and  the  predisposing 
causes  are  overwork,  worry,  lack  of  exercise,  certain  specific 
infections,  especially  influenza  and  gonorrhoea,  and  ^'isce^o- 
ptosis,  or  more  particularly  movable  kidney. 

Excessive  child-bearmg  and  the  menopause  are  frequent 
causes  of  neurasthenia  in  women. 

Injury  or  accident  may  determine  the  start  of  neurastlienic 
symptoms  (traumatic  neurasthenia),  anil  these  may  continue 
indefinitely,  or  they  may  clear  up  when  compensation  has 
been  paid.     Such  patients  are  not  necessarily  malingerers. 

The  outstanding  Symptoms  of  neurasthenia  are  : — 

(i.)  Irritability  and  inability  to  focus  the  attention  or  to 
concentrate  on  any  particular  matter  or  to  make  up  the 
mind  on  any  given  question. 

(ii.)  Insomnia. 

(iii.)  Extreme  depression,  often  amounting  to  a  sense  of 
complete  hopelessness  bordering  on  melancholia. 

(iv.)  A  tendency  to  worry  about  trifles  that  ordinarily 
woukl  be  brushed  aside  as  of  no  importance. 

(v.)  Easy  physical  fatigue  and  sense  of  inability  to  make 
any  bodily  effort. 

(vi.)  Introspection  so  overwhehning  that  the  patient  can 
talk  of  nothing  but  his  oww.  symptoms. 


590  MEDICAL   DIACiNOSLS 

(vii.)  Pains  in  the  head,  back  and  limbs  ;  there  is  often  a 
tingling  sensation  in  the  scalp  and  down  the  spine. 

Different  cases  exhibit  different  clinical  types.  One  will 
have  a  gastric  type  of  neurasthenia  with  prominent  dyspeptic 
phenomena  which  are  associated  with  secretory  neuroses 
of  the  stomach  or  with  visceroptosis  ;  another  will  have  a 
sexual  type  and  will  be  convinced  that  he  is  impotent  or 
unfit  to  marry,  usually  because  he  has  had  gonorrhoea  or 
syphilis,  or  else  because  he  is  worried  by  nocturnal  emissions. 

Most  patients  suffering  from  neurasthenia  lose  weight, 
have  a  subnormal  temperature,  and  are  constipated.  The 
urine  commonly  shows  an  excess  of  phosphates,  and  some- 
times there  is  a  definite  oxaluria. 

It  is  convenient  to  consider  as  a  special  class  of  neuras- 
thenia those  cases  which  are  more  accurately  labelled 
"  psychasthenia  "  and  which  manifest  a  definite  obsessive 
idea,  such  as  a  fear  of  the  dark,  a  fear  of  a  crowd,  a  fear  of 
being  alone,  a  fear  of  open  spaces,  etc.,  etc. 

Well-marked  cases  of  psychasthenia  are  also  liable  to 
attacks  of  giddiness  and  to  curious  dreamy  states,  in  which 
the  most  prominent  feature  is  a  sense  of  unreality  of  the 
surroundings,  but  in  which  there  is  no  true  unconsciousness, 
as  in  epilepsy. 

The  diagnosis  of  neurasthenia,  as  of  hysteria,  must  only 
be  made  when  the  most  careful  and  repeated  investigation 
has  failed  to  show  any  evidence  of  organic  nervous  disease. 
Movable  kidney  (especially  in  women)  must  always  be  looked 
for,  not  for  the  purpose  of  excluding  but  rather  of  confirming 
the  possibility  of  neurasthenia. 

It  is  especially  important  to  exclude  the  following  :— 

(i.)  Dementia  Prcecox.  Neurasthenia  does  not  occur 
at  the  time  of  puberty  and  is  extraordinarily  rare  before  the 
age  of  21  or  22  ;  hence  neurasthenic  symptoms  before  20 
years  of  age  should  arouse  suspicion  of  mental  disorder. 

(ii.)  General  Paralysis.  This  may  commence  with  purely 
neurasthenic  symptoms. 

There  should,  however,  be  some  organic  signs.  If  there  is 
doubt  an  examination  of  the  cerebro-spinal  fluid  should  be 
made  {vide  p.  512). 


PART   Yl 

CERTAIN    DISEA.^ES   OF  THE    SKIN 

A  CERTAIN  number  of  skin  affections  have  already  been 
discussed  in  so  far  as  they  are  manifestations  of  some  under- 
lying morbid  process — for  example,  the  eruptions  associated 
with  some  of  the  specific  infective  fevers  have  been 
described  under  the  headings  of  those  diseases,  and  the 
cutaneous  phenomena  which  may  be  met  with  in  sj^jhilis 
and  tuberculosis  have  been  similarly  dealt  with.  There 
remains  a  large  number  of  what  may  be  termed  prin>ary 
affections  of  the  skin  in  which  the  local  condition  is  the  only, 
or  at  any  rate  the  principal,  evidence  of  disease. 

An  accurate  classification  of  diseases  of  the  skin  is  impos- 
sible, because  the  pathology  of  manj'^of  these  conditions  is  at 
present  far  from  clear. 

In  the  short  description  which  follows  the  more  important 
skin  diseases  are  divided  roughly  into  four  groups,  an 
arrangement  which  is  convenient  rather  than  scientifically 
accurate. 

I.  Disorders  of  the  Cutaneous  Functions. 

II.  Toxic  and  Organic  Diseases  of  the  Skin. 

III.  New  Growths  of  the  Skin. 

IV.  Parasitic  Affections  of  the  Skin. 

The  primary  lesions  which  are  met  A\ith  in  diseases  of  the 
skin  may  be  defined  as  follows  : — 

(a)  Macule.  A  macule  is  a  stain  or  spot  due  to  pig- 
mentation {e.g.,  a  freckle  or  the  appearance  seen  after  a 
s\'philitic  eru})tion)  :  it  does  not  fade  on  pressure. 

(6)  Papule.  A  papule  is  a  small  solid  elevation  of  the 
cuticle  with  an  inflamed  base  :  the  size  varies  from  that  of 
a  pin's  head  to  that  of  a  pea. 

(c)  Nodule.  A  nodule  is  a  solid  elevation  of  the  skin 
of  larger  size  than  a  papule. 

{(I)   Vesicle.     A  vesicle  is  a  small  blister-like  elevation 


502  MEDICAL    DIAGNOSIS 

of  the  cuticle  :  it  contains  fluid  which  may  be  clear  or 
turbid  but  is  not  purulent. 

(e)  BuUa.     A  bulla  is  merely  a  large  vesicle. 

(/)  Piisftdp.  A  pustule  is  a  vesicle  with  purulent 
contents. 

(g)  Pomjyhus.  A  ])omphus  or  wheal  is  a  rounded 
elevation  due  to  acute  inflammatory  oedema. 

(A)  Erythema.  Erythema  (strictly  speaking)  is  merely  a 
local  congestion  or  superficial  redness  of  the  skin  which 
fades  on  pressure. 

I   DISORDERS  OF  THE  CUTANEOUS  FUNCTIONS. 

1.  Affections  of  the  Skin,  (i.)  Pruritus.  By  pruritus 
is  meant  the  subjective  sensation  of  itching  without  any 
further  objective  change  in  the  skin  than  may  be  caused  by 
scratching. 

Pruritus  may  be  local  or  general  :  the  former  is  usually 
limited  to  the  rectum  or  to  the  female  genitals  ;  the  latter 
is  seen  in  the  very  old,  in  cases  of  jaundice,  glycosuria  or 
gout,  in  morphino -maniacs,  and  also  sometimes  in  cold 
weather  (pruritus  hiemalis). 

A  curious  variety  of  pruritus  is  that  known  as  "  bath 
pruritus,"  in  which  contact  with  water  is  followed  by  intense 
itching  of  the  part  wetted. 

The  diagnosis  of  pruritus  depends  upon  the  absence  of  any 
local  changes  such  as  might  result  from  scabies  or  pediculosis. 

The  examination  of  the  urine  to  exclude  diabetes  must 
never  be  forgotten  in  cases  of  pruritus,  and  in  young  children 
the  fseces  must  be  investigated  for  the  presence  of  thread 
worms,  which  are  a  frequent  cause  of  localised  pruritus. 

(ii.)  Pigmentary  Changes,  (a)  Albinism  is  a  congenital 
absence  of  pigment  from  the  skin,  eyes,  and  hair.  The  eyes 
are  pink  and  the  hair  is  white.  Vision  is  usually  defective, 
and  nystagmus  is  nearly  always  present.  The  condition 
is  often  familial. 

(6)  Lentigo  (Ephelis  or  Frecldes).  Freckles  are  usually 
most  numerous  in  red-headed  persons ;  they  are  induced 
or  increased  by  the  rays  of  the  sun  and  are  rare  in  infancy. 

(c\  Evhelis  ah   inne  is  the  brown,   mottled,   or   marbled 


CERTAIN   DISEASES    OF   THE   SKIN  503 

appearance  which  is  seen  on  the  shins,  or  more  rareh'  on  the 
^\Tists  and  forearms,  of  cooks  and  persons  who  are  constantly 
exposed  to  the  heat  of  a  large  fire. 

(d)  Leucoderma  (Vitiligo).  In  leucoderma  there  are 
iiregular  but  sharply-defined  pale  areas  of  skin  which  are 
usually  surrounded  b}'  darker  skin  than  normal.  The  patches 
may  be  large  or  small,  and  if  the  scalp  is  affected  the  hair 
of  the  pale  areas  is  itself  colourless. 

(e)  Chloasma.  This  is  shown  by  patches  of  yellow  or 
brown  discoloration  (larger  than  freckles)  about  the  neck  and 
forehead  of  certain  women,  especially  during  pregnancy  or 
at  times  of  menstrual  disturbance. 

II.  Disorders  of  the  Hair,  (i.)  Alopecia  (Baldness)  is  a 
natural  manifestation  of  advancing  age,  but  occurs  pre- 
maturely in  males  to  a  very  large  extent.  In  some  cases  it  is 
hereditary  or  constitutional,  but  more  often  it  depends  upon 
a  bacterial  infection  of  the  hair  follicles  and  sebaceous 
glands.  Partial  baldness  sometimes  follows  acute  fevers, 
and  is  a  common  manifestation  of  sj^hilis. 

(ii.)  Alopecia  Areata.  This  condition  is  characterised  by 
a  rapid  and  complete  baldness  over  certain  well-defined 
and  sharply-delimited  areas  of  the  scalp. 

In  most  cases  the  hair  eventually  grows  again,  but  the 
new  crop  may  be  white. 

The  diagnosis  must  be  made  from  ringworm  by  the  absence 
of  the  broken-off  stumps,  in  which  the  fungus  of  this  latter 
disease  can  be  demonstrated  microscopically. 

(iii.)  Canities  or  Greyness,  is  due  to  loss  of  pigment  from 
the  hairs  ;  it  may  be  partial  or  complete,  local  or  diffuse,  and, 
like  baldness,  is  a  natural  ])henomenon  of  increasing  age, 
though  often  seen  prematurely. 

III.  Disorders  of  the  Sebaceous  Glands,  (i.)  Milium. 
This  is  a  very  small,  round  white  tumour  in  the  skin  due  to 
the  retention  of  sebaceous  matter  in  a  sebaceous  gland.  The 
tumours  are  generally  multiple  and  may  be  very  numerous. 
They  are  most  (•f)mmon  on  the  eyelids,  cheeks,  scrotum, 
and  penis.  If  the  tumours  are  punctured  the  sebaceous 
matter  can  be  squeezed  out. 

(ii.)  Comedo  (Blackhead).     This  is  caused  by  distension 
of  a  hair  follicle  with  sebaceous  matt^^r.     The  opening  of  the 
M.I).  38 


594  MEDICAL   DIAGNOSIS 

follicle  on  the  skin  is  choked  with  greasy  sebum,  which  soon 
becomes  blackened  with  dirt  and  so  gives  the  characteristic 
appearance, 

(iii.)  Seborrhoea.  This  is  due  to  excessive  secretion  of 
sebaceous  matter,  and  occurs  in  two  main  forms — seborrhoea 
sicca  and  seborrhoea  oleosa. 

Seborrhoea  sicca  always  occurs  first  in  the  scalp  :  it  is 
essentially^  an  infective  process.  An  invasion  by  the  bottle 
bacillus  of  Unna  is  the  first  stage  ;  this  causes  epidermal 
desquamation,  which  is  shown  clinically  by  dry  scurfy 
flakes  in  the  hair. 

The  second  stage  commonly  occurs  about  puberty  and 
depends  upon  an  infection  with  the  Staphylococcus  epider- 
midis  albus  (grey  skin-coccus).  The  scurf  becomes  more 
greasy  and  the  hair  tends  to  fall  out. 

The  third  stage  is  one  of  oily  seborrhoea  and  depends  upon 
the  invasion  of  the  fatty  matter  in  the  ducts  of  the  sebaceous 
glands  by  the  acne  bacillus. 

Primary  oUy  seborrhoea  is  more  common  about  the 
face. 

Both  forms  of  seborrhoea  may  be  found  on  the  trunk  and 
limbs.  Clinically  the  lesions  on  the  scalp  vary  greatly  in 
intensity  ;  there  may  be  nothing  more  than  an  excess  of 
scurf,  which  drops  out  on  the  coat -collar  and  is  especially 
noticeable  on  brushing  the  hair,  or  there  may  be  definite 
papular  crops  round  an  area  of  hypersemia,  surmounted 
by  a  cake  of  greasy  scales.  More  or  less  itching  is  usually 
complained  of. 

Seborrhoea  is  common  in  infancy,  and  if  neglected  may  be 
followed  by  eczema. 

On  the  trunk  the  chief  lesions  are  crops  of  papules.  These 
run  together  into  scaly  patches  which  are  more  or  less 
hypergemic  ;  they  spread  peripherally  and  tend  to  improve 
centrally,  so  that  rings  are  formed.  The  limbs  are  rarely 
affected. 

The  diagnosis  must  be  made  from  psoriasis  by  the  softer, 
greasier,  and  less  glistening  character  of  the  scales,  by  the 
distribution  (psoriasis  starts  about  the  knees  and  elbows), 
and  by  the  evidence  of  seborrhoea  in  the  scalp  ;  and  from 
pityriasis  rosea  by  the  absence  of  the  initial  papules  in  this 


CERTAIN   DISEASES   OF   THE   SKIX  595 

latter,  as  well  as  by  its  relative  preference  for  the  limbs 
(vide  also  p.  608). 

IV.  Disorders  of  the  Sweaty  Glands,  (i.)  Anidrosis. 
Absence  of  perspu-ation  may  occur  generally  in  myxoedema 
or  such  wasting  diseases  as  diabetes  or  locally  in  ichthyosis, 
scleroderma,  psoriasis,  eczema,  and  the  anaesthetic  form  of 
leprosy. 

(ii.)  Hyperidrosis.  Excess  of  perspiration  may  occur  in 
certain  febrile  wastuig  diseases  such  as  tuberculosis,  in 
metabolic  disorders  such  as  Graves'  disease,  in  certain 
lesions  of  the  nervous  system,  or  as  a  constitutional  condi- 
tion. 

(iii.)  Bromidrosis.  Foul-smelling  perspiration  is  usually, 
but  not  always,  associated  with  excessive  secretion.  It  is 
seen  in  certain  diseases  such  as  rheumatic  fever  and  sCurvy, 
but  also  occurs  in  certain  unfortunate  persons  who  are 
perfectly  healthy  otherwise.  In  these  cases  the  bromidrosis 
is  generally  localised  to  the  feet.  The  perspiration  does  not 
smell  unduly  when  it  is  first  secreted,  but  the  subsequent 
odour  depends  on  the  presence  of  the  Bacillus  foetidus. 

II.  TOXIC  AND  ORGANIC  DISEASES  OF  THE 

SKIN. 

I.  Acne,  (a)  Acne  Vulgaris.  The  essential  lesion  in 
acne  vulgaris  is  a  red  papule  which  may  or  may  not  pustulate. 
The  papules  are  the  direct  result  of  inflammation  in  blocked 
sebaceous  glands  or  hair  follicles. 

The  inflammation  is  produced  by  the  action  of  the  acne 
bacillus  or  the  staphylococcus  epidermidis  alb  us  (grey 
coccus). 

The  lesions  are  most  prevalent  on  the  face,  shoulders, 
back,  and  thorax  ;  those  that  suppurate  often  leave  minute 
white  scars. 

Acne  vulgaris  usually  develops  about  the  age  of  puberty 
and  often  disappears  at  2.")  or  thereabouts. 

Persons  with  coarse,  greasy  skins  are  princiipally  att'ectrd. 

The  diaguijsis  does  not  present  any  difficulty ;  the  distribu- 
tion of  the  eruption,  the  associated  comedones,  and  the  age 
of  the  patient  are  usually  characteristic,  thoufrh  the  possibility 

38—2 


596  MEDICAL   DIAGNOSIS 

of  a  pustular  syphilide  should  be  borne  iii  miiid  in  doubtful 
cases  and  other  evidence  of  syphilis  sought  for. 

(6)  Acne  Rosacea.  This  disease  affects  the  skm  of  the 
middle  third  of  the  face.  It  varies  in  mtensity  from  a  simple 
hyperemia  to  a  condition  of  rhinophyma,  in  which  there  is 
hypertrophy  and  lobulation  oi  the  skm  of  the  nose,  the  result 
of  chronic  inflammation  around  over-secretmg  or  blocked 
sebaceous  glands.     There  is  no  tendency  to  ulceration. 

Acne  rosacea  is  more  common  m  women  than  men, 
and  usually  develops  in  the  third  or  fourth  decade  ;  in  either 
sex  dyspepsia  and  alcoholism  are  predisposmg  factors. 

The  diagnosis  is  easy.  Lupus  erythematous  can  be  dis- 
tinguished by  its  raised  spreadmg  edge  and  its  scaliness  ; 
tertiary  syphilis  by  its  symmetry  and  tendency  to  ulceration  ; 
acne  vulgaris  by  the  younger  age,  the  wider  distribution, 
and  the  presence  of  comedones. 

II.  Cheiropomphoiyx.  This  condition  manifests  itself  by 
a  symmetrical  eruption  of  vesicles  about  the  extremities, 
especially  about  the  hands.  Women  are  more  affected  than 
men,  and  the  eruption  is  usually  only  present  in  hot  weather. 

Clinically  the  first  symptom  is  burning  and  itchmg. 
The  vesicles  appear  after  a  short  interval  ;  at  first  they 
are  deeply  imbedded  m  the  skm,  but  as  they  reach  the  surface 
they  run  together  and  form  large  bullae.  The  bullse  gradually 
dry  up  and  leave  a  crust,  which  droops  off  and  exposes  a 
very  tender  area  of  pmk  new  skin.  Relapses  and  recur- 
rences are  common. 

Cheiropomphoiyx  can  be  diagnosed  by  the  characteristic 
development  of  the  bullse  and  thek  localisation  to  the 
extremities  ;  m  addition  it  is  distmguished  from  eczema  by 
the  absence  of  weepmg,  from  pemphigus  by  the  fusion  of 
the  vesicles  into  bullse,  and  from  ringworm  by  the  absence 
of  the  fungus  in  the  scrapings  from  the  lesions, 

III.  Eczema,  Eczema  is  defined  by  Sir  Malcolm 
Morris^  as  "a  catarrhal  inflammation  of  the  skin, 
origmatmg  without  visible  external  irritation  and  charac- 
terised by  serous  exudation  at  some  stage  of  its  evolution." 
The  same  author  points  out  that  this  definition  excludes 
skin  lesions  produced  by  chemical  or  mechanical  irritants, 

'  "Disease  of  the  Skm"  (Cassell,  1911). 


CERTAIN   DISEASES   OF   THE   SKIX  507 

although  such  lesions  clinically  and  anatomically  may  be 
indistinguishable  from  true  eczema. 

Descriptiox.  An  attack  of  eczema  is  preceded  by  tingling 
and  itching  in  the  part  about  to  be  affected. 

The  primary  lesions  may  be  papular,  vesicular,  or  ery- 
thematous. All  \vTiters  agree  that  vesicles  are  the  most 
constant  phenomena  although  they  may  be  extremely 
small  individually. 

In  the  papular  type  a  minute  vehicle  can  often  be  recog- 
nised at  the  summit  of  the  papule,  and  these  when  scratched 
off  may  be  replaced  by  a  small  scab  of  blood. 

There  is  a  great  tendency  for  the  disease  to  spread  peri- 
pherally while  healing  centrally,  and  to  heal  up  temporarily 
only  to  break  out  again  in  the  same  or  in  some  other  part. 

Most  cases  of  eczema  present  the  following  more  or  l^s  ill- 
defined  stages  (all  of  which  maybe  present  simultaneously) : — 
(a)  Erythema.  (6)  Vesiculation.  (c)  The  exudation  of  a 
clear  fluid  (which  stiffens  linen)  from  a  red  angry  surface. 
(d)  Scabbing,  in  which  the  discharge  forms  greyish-yellow 
crusts,  (e)  Desquamation  after  the  crust  formation  has 
ceased. 

It  is  easy  to  understand  that  the  possibility  of  secondary 
infections  with  pyogenic  micro-organisms  is  very  great, 
and  this  is  enhanced  when  it  is  remembered  that  the  itching 
is  often  so  intolerable  that  it  is  out  of  the  question  to  refrain 
from  scratchuig.  Such  secondary  infections  may  modify 
the  primary  features  of  the  lesions  very  considerably  ; 
pustules  and  boils  are  common,  so  that  it  may  be  said  that 
tli(ne  is  no  skin  disease  which  may  present  such  varied 
appearances  as  eczema. 

The  distribution  of  eczema  presents  certain  important 
features,  though  there  is  no  part  of  the  body  tlwit  may  not 
be  affected.  There  appears  to  be  an  especial  predilection 
for  the  fleror  aspects  of  joints,  the  ^grooves  behind  the 
ears,  the  scalp,  the  breasts  of  women,  and  the  palms  of  the 
hands  and  soles  of  the  feet.  The  genitals,  the  arms,  the 
umbilicus,  and  the  nipples  are  not  infrequently  attacked. 

Eczema  is  especially  common  in  infancy  and  in  old  age. 
I  u  infants  the  scalp  and  face  are  particularly  prone  to  attack, 
but  the  whole  body  may  be  involved. 


598  MEDICAL  DIAGN08TR 

tSeborrhoeic  eczema.  AA'hich  is  probably  nothing  more  than 
eczema  which  has  developed  on  a  chronic  seboiihoea,  is  the 
variety  usually  met  with  in  infanc}^.  childhood,  and  at 
puberty. 

An  interesting  clinical  point  is  the  tendency  for  chronic 
eczema  to  alternate  with  certain  chronic  conditions, especially 
bronchial  asthma  and  gout ;  when  the  patient  has  eczema 
he  is  free  from  asthma  or  gout,  and  vice  versa.  In  like  manner 
it  is  only  too  frequently  found  that  an  infant  with  acute 
eczema  recovers  from  the  eczema  only  to  perish  forthwith 
from  acute  pneumonia  ;  this  distressing  sequel  has  especially 
been  observed  in  those  babies  whose  eczema  has  yielded 
exceptionally  quickly  to  treatment. 

Diagnosis.  The  diagnosis  can  usually  be  established  if 
a  careful  examination  of  all  the  lesions  is  made  with  a  lens 
after  bathing  off  all  crusts  and  secretions. 

Erythema  viulfiforme  presents  neither  scales  nor  weepmg. 

Secondary  syphilis  does  not  itch— there  are  other  evidences 
of  syphUis  ;  the  treponema  can  be  demonstrated  in  scrapings 
from  the  lesions,  and  the  Wassermann  reaction  is  positive. 

Erysipelas  is  generally  accompanied  by  severe  constitu- 
tional disturbance  and  shows  a  typical  raised  edge  (vide 
p.  25). 

Scabies  should  be  suspected  from  the  distribution  {vide 
p.  616)  and  from  the  linear  arrangement  of  the  lesions. 
Proof  positive  is  afforded  by  the  discovery  of  the  charac- 
teristic burrows  in  the  skin. 

Tinea  cruris  and  Tinea  circinata  can  be  diagnosed  by 
the  discovery  of  the  fungus. 

Psoriasis  never  "  weeps  "  and  has  a  much  more  definite 
edge  than  eczema ;  its  predilection  for  the  extensor  aspects 
of  the  elbows  and  knees  is  in  distinct  contrast  to  most  cases 
of  eczema  and  the  scales  are  much  more  white  and  "  silvery." 

Lichen  planus  never  discharges  or  forms  crusts,  and  the  in- 
dividual papules  are  a  much  darker  red  than  those  of  eczema. 

Favus  has  cup-shaped  sulphur-yellow  crusts  and  possesses 
a  strong  odour  of  mice  ;  further,  the  specific  fungus  can 
readily  be  demonstrated. 

Pityriasis  rubra  does  not  itch,  does  not  ''  weep,"  and  does 
not  form  crusts. 


CERTAIN   DISEASES   OF   THE   SKIX  509 

The  frequency  with  which  eczema  (especially  of  the  genitals) 
is  found  as  a  manifestation  of  diabetes  indicates  the  necessity 
for  examining  the  urine  for  sugar  in  all  cases.  The  possibility 
of  an  underlying  gouty  diathesis  must  also  be  borne  in  mind. 
IV.  Erythema.  Two  main  groups  of  erythema  can  be 
recognised — first,  hypersemic  erythema,  and,  secondly,  in- 
flammatory erythema.  In  the  In^persemic  form  the  initial 
active  congestion  is  followed  by  passive  congestion  from 
vaso-motor  paralysis,  and  the  bright  red  colour  is  replaced 
by  a  livid  purple  as  the  sensation  of  heat  disappears  and  the 
local  temperature  falls. 

In  the  inflammatory  form  there  is  stasis  of  the  blood- 
stream, with  the  possibility  of  subcutaneous  haemorrhages 
and  the  occurrence  of  vesicles,  oedema,  pigmentation,  etc. 

Presumably  erythema  is  the  result  of  vaso-motor  insta- 
bility, whereby  there  is  an  excessive  response  to  stimulation, 
whether  direct  (heat,  cold,  fomentations,  insect  bites,  etc.) 
or  indirect  (toxins  of  rheumatism,  gout,  intestinal  stasis, 
etc.). 

Hyper^mic  Erythema.  The  following  varieties  are 
described  : — 

(a)  Erythema  Simplex.  Hot,  red  patches,  which  may 
occur  anywhere,  but  are  most  frequent  on  the  face  and  other 
exposed  parts.  There  is  itching  and  a  .sensation  of  heat. 
After  a  variable  time  the  colour  fades,  the  heat  disappears 
and  a  branny  desquamation  often  follows.  There  ig  no 
constitutional  disturbance  and  no  well-defined  edge  as  in 
erysipelas. 

{h)  Erythema  Fugax.  Except  for  its  transient  character, 
erythema  fugax  is  identical  with  erythema  simplex.  It  is 
e.specially  liable  to  develop  in  children  from  the  reflex 
irritation  associated  with  gastro-intestinal  disturbance, 
teething,  worms,  etc. 

Inflamm.atory  Erythema.  The  following  varieties  are 
described  : — 

[a)  Erythema  Intertrigo,  which  develops  where  opposing 
skin  surfaces  are  in  contact,  especially  in  the  groins,  thighs, 
axillae,  and  under  pendulous  breasts.  Eczema  often  super- 
venes in  these  cases. 

The  napkin  rash  of  infants  is  an  example  of  this  form 


GOO  MEDICAL   DIAGNOSIS 

of  erythema  ;  it  may  closely  resemble  a  congenital  syphi- 
litic rash,  but  is  strictly  confined  to  the  area  covered  by  the 
napkin,  whereas  the  syphilitic  rash  is  not  so  limited. 

(6)  Erythema  Paratrimma  is  the  livid  discoloration 
which  precedes  the  formation  of  a  bedsore. 

(c)  Erythema  Loeve  is  the  dusky  appearance  which  is 
so  often  seen  in  oedematous  legs  and  which  is  sometimes  a 
warning  that  sloughing  is  about  to  occur. 

(d)  Erythema  Pernio  (Chilblain)  is  met  with  in  cold 
weather,  and  principally  in  children  and  the  aged.  The 
characteristic  lesion  is  the  formation  of  small  dusky,  red 
or  even  bluish  patches  on  the  hands  and  feet,  though  the 
ears  and  nose  may  be  affected  also. 

The  dorsum  and  sides  of  the  fingers  and  the  heel  and  outer 
edge  of  the  foot  and  the  little  toe  are  the  most  common 
sites.  Itching  is  extreme  and  there  is  2;reat  local  tender- 
ness ;    ulceration  is  not  uncommon. 

(e)  Erythema  Multiforme.  This  condition  is  a  toxic  in- 
flammation of  the  skin  :  the  nature  of  the  toxin  or  toxins 
is  uncertain  ;  probably  many  can  produce  the  same  result. 
There  is  no  evidence  that  rheumatism  is  especially  associated 
with  this  condition. 

The  lesions  may  be  papular,  vesicular,  oedematous, 
nodular,  hsemorrhagic,  or  bullous. 

There  is  usually  constitutional  disturbance  at  the  outset, 
such  as  fever  and  malaise,  as  well  as  sore  throat,  joint 
pains,  and  gastro -intestinal  disturbance. 

The  eruption  is  usually  first  seen  on  the  backs  of  the 
hands  or  the  dorsum  of  the  feet,  and  spreads  thence  up  the 
limbs  to  the  trunk  and  face. 

The  prmiitive  lesion  is  generally  a  crop  of  tiny  bright-red 
papules.  The  skin  surrounding  the  individual  lesions  is 
congested. 

The  patches  often  subside  in  the  centre  while  spreading 
peripherally,  so  that  ring  and  serpentine  form«  are  common 
(erythema  annulare  ;    erythema  gyratum). 

Vesicles  and  bullae  may  form  at  the  margins  of  the  lesions 
and  haemorrhages  may  occur  into  the  papules. 

The  average  duration  of  erythema  multiforme  is  four  to 
six  weeks,  but  recurrences  are  very  common. 


CERTAIN  DISEASES   OF   THE   SKTX  001 

Erythema  Iris  is  a  variety  of  erythema  multiforme, 
but  it  is  frequently  the  only  manifestation.  The  appearances 
are  characteristic  :  there  is  a  central  papule  surmounted  by 
a  vesicle  and  surrounded  by  an  inflammatorj^  areola  on 
which  a  ring  of  secondary  vesicles  appears,  whilst  outside 
these  again  there  is  a  second  and  even  a  third  ring  of 
vesicles. 

The  primary  central  vesicle  dries  up  and  forms  a  scab 
which  drops  off. 

Occasionally  bullae  replace  the  vesicles  m  erythema  iris. 
(/)  Erytheina  Nodosum.  The  characteristic  feature  of  this 
condition  is  the  development  of  multiple  node-like  swellings 
on  the  legs  and  feet  and  less  often  on  the  tliighs.  forearms, 
and  shoulders.  The  nodes  are  roughly  oval  in  outline  and 
tend  to  have  theu-  long  axes  in  that  of  the  limb  ;  they  vary 
in  size  from  that  of  an  almond  to  that  of  a  hen"s  egg,  And 
are  very  tender  but  not  painful.  At  first  they  are  bright 
red  in  colour  ;  later  they  go  through  all  the  colour  changes 
of  a  bruise  ;  they  appear  to  soften  almost  to  the  point  of 
fluctuation,  but  never  suppurate. 

Each  node  lasts  for  about  fourteen  daj^s,  but  successive 
crops  appear  at  short  intervals,  so  that  the  duration  of  the 
illness  is  about  four  to  six  weeks. 

Children  and  young  adults  are  most  frequently  affected, 
and  the  female  sex  predominates. 

There  is  sometimes  a  mild  constitutional  disturbance 
in  the  earl}^  stages  and  nearh^  always  pain  in  the  joints  and 
down  the  legs.  It  was  formerl}-  thought  that  erythema 
nodosum  was  a  manifestation  of  rheumatism,  but  careful 
analysis  of  jnan}^  cases  has  shown  that  this  hypothesis 
is  probably  incorrect. 

The  nature  of  the  toxin  which  is  responsible  for  this 
form  of  erythema  remains  unknown,  but  it  is  sigiiihcant 
tiiat  a  very  large  percentage  of  cases  give  a  positive  cutanco- 
tuberculin  (von  Pirquet)  reaction. 

The  diagnosis  of  erythema  nodosum  is  usiudly  quite 
obvious.  Septic  conditi<;ns  sudi  as  osteomyelitis  are  accom- 
panied by  pain  and  severe  constitutional  disturbance.  The 
early  stages  of  nodular  leprosy  can  be  diagnosed  by  the 
presence  of  ana36thesia  in  or  about  the  notlules  ;  gummatous 


602  MEDICAL  DIAGNOSIS 

formation  is  not  accompanied  by  joint  pains  and  tends  to 
ulcerate. 

{g)  Erythema  Scarlatiniforme.  This  condition  may  simu- 
late scarlet  fever  very  closely  ;  there  is  febrile  disturbance, 
followed  in  a  few  hours  by  a  vivid  red  erythema  which  may 
invade  the  whole  body.  The  tongue  is  foul  with  prominent 
papillse  and  the  throat  is  injected.  Relapses  are  common, 
and  the  duration  of  illness  may  be  many  weeks. 

A  positive  diagnosis  between  this  condition  and  scarlet 
fever  is  impossible  in  the  early  stages  ;  the  most  strilcing 
difference  is  the  early  onset  of  desquamation  (often  on  the 
second  day)  in  erythema  scarlatiniforme. 

The  rash  of  scarlet  fever  never  lasts  more  than  eight  to  ten 
days,  whereas  in  erythema  scarlatiniforme  it  may  persist 
for  several  weeks. 

V.  Herpes,  (a)  Herpes  Facialis.  This  is  characterised 
by  an  eruption  of  vesicles  on  a  red  hypersemic  base.  The 
usual  site  is  the  muco-cutaneous  junction  of  the  lips  and 
nose  ;  the  mucous  membrane  of  the  cheeks  or  tongue  may 
be  affected.  The  condition  is  often  bilateral  and  is  commonly 
seen  in  ordinary  colds.  The  occurrence  of  labial  herpes  in 
lobar  pneumonia  and  cerebro-spinal  meningitis  is  a  striking 
feature  of  these  diseases. 

(6)  Herpes  Genitalis  is  a  similar  condition  to  the  above 
which  affects  the  prepuce  and  glans  penis  in  men  or  the  labia 
and  cervix  uteri  in  women. 

(c)  Herpes  Zoster  (Shingles).  This  affection  is  character- 
ised by  the  eruption  of  clusters  of  vesicles  on  an  erythematous 
background  along  the  area  of  cutaneous  distribution  of  one 
or  more  posterior  nerve  roots.  There  is  often  severe  pain 
before,  during,  and  even  after  the  eruption. 

Herpes  zoster  is  nearly  always  unilateral,  hardly  ever 
recurs,  and  depends  on  some  inflammatory  or  haeniorrhagic 
lesion  in  the  corresponding  posterior  root  ganglia. 

VI.  Dermatitis  Herpetiformis.  This  is  a  chronic  affection 
of  the  skin  characterised  by  polymorphous  lesions,  tending  to 
herpetiform,  pemphigoid,  and  urticarial  types,  accompanied 
by  severe  itching,  but  not  as  a  rule  attended  by  any  consider- 
able constitutional  disturbance.  Scarring  and  pigmenta- 
tion are  common  when  the  lesions  heal, 


CERTAIN   DISEASES   OF   THE   SKTX  603 

The  affection  is  bilateral,  and  both  shin  and  mucous 
membranes  may  be  involved.  The  sexes  are  equally  liable 
and  all  ages  are  attacked. 

An  interesting  feature  is  the  presence  of  an  excess  of 
eosinophile  cells  both  in  the  blood  and  in  the  fluid  from  the 
bulla?. 

The  diagnosis  depends  upon  the  diverse  character  of  the 
lesion,  the  intense  itching,  the  frequent  relapses,  and  the 
bilateral  distribution. 

Herpes  zoster  is  distinguished  by  its  accurate  localisation 
to  certain  nerve  root  areas  and  its  unilateral  distribution. 

VII.  Impetigo  Contagiosa.  The  disease  is  seen  as  a  rule 
in  the  children  of  the  poor  who  are  neglected  and  underfed. 
It  is  caused  by  a  streptococcal  infection  of  the  skin  and 
manifests  itself  as  a  pustular  eruption,  usually  about  the 
head  and  face.  ' 

The  primary  lesion  is  vesicular,  but  the  vesicules  soon 
})ustulate. 

The  pustules  dry  up  into  scabs,  but  often  coalesce  first, 
so  that  large  crusts  are  formed, 

A  striking  feature  is  the  absence  of  any  hypersemia  around 
the  pustules  or  scabs. 

The  neighbouring  lymph  glands  are  generally  enlarged, 
but  the  constitutional  disturbances  are  relatively  slight. 
The  disease  is  readily  inoculable  by  means  of  the  dis- 
charges. 

The  only  difficulty  in  diagnosis  lies  in  excluding  a  pustular 
form  of  eczema.  The  chief  points  are  that  there  is  no  inflamed 
skin  round  the  individual  lesions  in  impetigo,  that  there  is 
little  or  no  itching,  that  there  is  no  attempt  at  s^-mmetry, 
and  that  the  disease  clears  up  with  great  rapidity  if  suitable 
treatment  (e.j/.,  white  precipitate  ointment)  is  applied. 

VIII.  Lichen  Ruber  Planus.  The  characteristic  lesions 
in  this  affection  are  small,  irregularly-shaped  papules, 
generally  with  flat  tops  though  sometimes  umbilicated. 

The  papules  are  purple  in  colour,  and  in  the  centre  of  each 
is  a  small  scale.  They  tend  to  arrange  themselves  in  rings 
or  lines,  are  very  closely  packed,  and  often  confluent. 

The  usual  situations  are  the  flexor  aspects  of  the  wrists, 
the  jjopliteal  spaces,  and  the  limbs  generally,  but  the  whole 


604  MEDICxAL   DIAGNOSIS 

body  may  be  affected,  and  in  a  considerable  proportion  of 
cases  the  mucous  membranes  are  involved  also. 

The  rash  is  always  dry  and  as  it  fades  leaves  dark  stains 
which  gradually  fade  into  white  patches.  True  scars  are 
never  met  with.     Itching  is  often  severe. 

Lichen  planus  may  occur  at  any  age,  though  children  and 
the  very  old  usually  escape.  The  causation  is  unknown,  but 
it  may  follow  profound  emotional  disturbance. 

The  diagnosis  must  be  made  from — 

{a)  Papular  Eczema  {vide  p.  598). 

(6)  Psoriasis  by  the  fact  that  the  individual  papules  do 
not  spread  out  into  scaly  patches  and  that  the  general 
scaliness  is  much  less  marked  {vide  p.  610). 

(c)  Papidar  Syphilides  by  the  dryness  of  the  papules  and 
the  Wassermann  reaction. 

{d)  Pityriasis  Rubra  Pilaris  {vide  p.  608). 

IX.  Lupus  Erythematosus.  This  is  an  inflammatory 
affection  of  the  skin  Avhich  usually  is  confined  to  the  cheeks, 
nose,  and  ears,  though  other  parts  may  be  affected.  In 
many  cases  there  is  a  pre-existing  chronic  seborrhoea. 
Women  are  much  more  commonly  affected  than  men,  and 
the  disease  usually  starts  between  the  ages  of  25  and  45. 
It  runs  a  very  chronic  course  and  tends  to  die  out  in  from 
fifteen  to  twenty  years,  leaving,  however,  permanent 
atrophic  deformity  of  the  affected  skm. 

The  primary  lesions  are  minute  red  papules  which  mcrease 
and  coalesce  to  form  rounded  patches.  They  usually 
appear  first  on  the  cheeks  and  spread  centrally  to  join  each 
other  over  the  bridge  of  the  nose,  thus  causing  the  typical 
"bats-wing"  appearance.  The  primary  spots  have  red, 
elevated  and  thickened  borders,  which  may  be  covered  by  a 
thin  scab  or  by  papery  scales.  Around  the  patches,  in  those 
parts  in  which  there  are  sebaceous  glands,  comedones  can  be 
observed  to  a  greater  or  less  extent. 

The  lesions  of  lupus  erythematosus  are  usually  sym- 
metrical. Sometimes  the  disease  advances  by  the  peripheral 
spread  of  the  primary  patches  (discoid  form),  in  others  by 
the  appearance  of  fresh  crops  of  spots.  The  mucous 
membranes  may  be  involved,  but  usually  only  by  direct 
extension. 


CERTAIN   DISEASES   OF   THE   SKIN  605 

The  diagnosis  depends  upon  the  chronicity  of  the  disease 
combined  with  tiie  characteristic  appearance  of  the  lesions, 
which  show  an  atrophic  centre,  a  raised  red  edge,  and  a 
girdle  of  sebaceous  plugs.  The  process  is  always  superficial 
and  never  ulcerates. 

hi  Lupus  Vulgaris  the  primary  lesion  is  a  soft  nodule,  the 
disease  mvades  deeper  structures,  ulceration  is  common, 
and  symptoms  nearly  always  appear  before  puberty. 

In  Acne  Rosacea  there  is  no  central  scar  and  no  surface 
scab. 

X.  Pellagra.  A  disease  of  obscure  causation,  endemic  iii 
Italy,  Roumania,  Egypt,  etc.  It  probably  has  a  far  wider 
incidence  really,  since  cases  have  been  recorded  in  England, 
France,  and  Spam,  and  it  is  by  no  means  uncommon  in 
America.  / 

It  was  for  a  long  time  thought  that  pellagra  resulted  from 
eating  overmuch  maize,  especially  decomposed  or  fermentmg 
maize,  but  recently  Dr.  Sambon  clauns  to  have  discovered 
a  protozoon  which  is  the  cause  of  pellagra  and  which  is 
conveyed  to  man  by  the  bite  of  a  smaU  black  fly.  The 
question  as  yet  remains  uncertain. 

The  course  of  pellagra  is  fairly  constant ;  the  first  symp- 
toms are  usually  noticed  m  the  spring,  and  consist  of  pain  in 
the  back,  limbs,  and  jomts,  with  fever,  gastro -intestinal 
disturbance,  and  general  malaise.  A  cutaneous  eruption 
soon  appears,  chiefly  on  the  exposed  parts  of  the  arms  and 
hands  ;  it  is  primarily  erythematous  in  character  but 
petechise  and  bullae  are  often  seen  ;  the  bullae  rupture  and 
leave  chronic  ulcers.  The  eruption  clears  up  in  about  two 
weeks  with  free  desquamation,  leavmg  thickening  and 
yellowish -brown  coloration  of  the  underlying  skm.  At  the 
same  time  a  spastic  paresis  develops,  particularly  m  the 
lower  limbs. 

Each  spring  there  is  a  further  similar  outbreak,  and 
eventually  the  skui  where  the  rash  appears  becomes  dry, 
wizened,  and  atrophic. 

The  paralytic  phenomena  progress  slowly  but  steadily, 
and  mental  changes  comparable  to  those  of  general  paralysis 
develop.  .Many  patients  become  melancholic  with  strong 
suicidal    tendencies    and    eventually    find    then    way    into 


606  MEDICAL   DIAGNOSIS 

asylums.  Life  is  prolonged  from  from  five  to  fifteen  years 
after  the  first  attack. 

XI.  Pemphigus.  This  consists  in  a  bullous  eruption 
developing  on  previously  healthy  skin. 

Three  varieties  are  described  : — 

(a)  Pemphigus  Vulgaris.  There  is  usually  some  febrile 
disturbance  at  the  outset.  The  bulla3  develop  in  a  few  hours 
into  tense  hemi-spherical  blisters  ;  they  vary  greatly  in 
size  and  number,  and  have  no  surroundmg  areola  of  in- 
flammation or  characteristic  distribution.  The  contents 
are  clear  at  first,  but  soon  become  opaque,  and  in  about 
three  days  the  bullae  dry  up  to  leave  a  brownish  scab  which 
drops  off  and  exposes  a  purple  patch  of  new  skin.  This, 
however,  eventually  assumes  a  quite  normal  appearance. 
The  bullae  appear  m  successive  crops,  so  that  the  condition 
may  persist  for  weeks  or  months. 

The  mucous  membranes  are  very  rarely  involved,  neither 
do  the  bullae  fuse  with  their  neighbours  as  a  rule.  Sometimes 
there  is  haemorrhage  into  some  of  the  bullae. 

Relapses  are  fairly  common  in  pemphigus  vulgaris,  and 
sometimes  the  disease  becomes  practically  continuous. 
It  sometimes  happens  that  the  eruption  is  so  extensive  and 
the  constitutional  disturbance  so  severe  that  death  takes 
place  in  a  few  weeks. 

(h)  Pemjjhigus  Foliacus.  This  variety  is  rare  :  the  initial 
bullae  are  not  rounded  and  tense,  but  more  or  less  flaccid 
from  the  outset ;  they  break  readily  and  form  yellowish 
crusts,  which  become  separated  and  expose  an  excoriated, 
angry-looking  surface.  The  lesions  progress  steadily,  until 
after  many  months  the  entire  skui  as  well  as  large  areas  of 
the  mucous  membrane  may  become  involved.  There  is 
constant  fever  and  extreme  discomfort  and  distress.  Most 
cases  end  fatally  from  exhaustion  and  toxic  absorption. 

(c)  Pemphigus  Vegetans.  This  variety  is  extremely  rare  : 
the  initial  lesions  are  small  bullae,  which  gradually  infiltrate 
and  elevate  the  surrounding  epidermis.  Excoriation  readily 
takes  place  and  leaves  a  bare  patch,  on  which  a  condyloma- 
tous  growth  is  formed  in  four  or  five  days.  This  papillary 
outgrowth  discharges  a  thin,  foul-smelling  secretion  and 
is  surrounded  by  a  ring  of  secondary  bullae. 


CERTAIN   DISEASES   OF    THE   SKIN  607 

The  female  genitals,  the  axilla?,  the  mouth,  the  hands, 
and  the  feet  are  usually  the  first  parts  to  be  attacked  ;  but 
gradually  large  areas  of  skin  are  mvolved,  the  epidermis 
strips  off  in  large  sheets,  and  superficial  gangrene  eventually 
develops.     A  fatal  result  is  to  be  exp(  ctcd. 

Li  all  forms  of  pemphigus  there  is  a  well-marked  eosino- 
philia. 

Diagnosis.  Pemphigus  Vulgaris  is  distinguished  from 
dermatitis  herpetiformis  and  bullous  varieties  of  urticaria 
or  erythema  by  the  single  character  of  the  lesion,  with  the 
absence  of  erjiihema  or  urticaria  around  the  bullae  ;  further, 
the  pigmented  areas  which  represent  earlier  bullae  are  quite 
characteristic. 

Pemphigus  Foliaceus  is  distinguished  from  eczema  by  its 
larger  scales  and  wider  distribution.  / 

Pemphigus  Vegetans,  even  more  than  the  other  varieties 
of  pemphigus,  must  be  distinguished  from  a  syphilitic 
condition.  In  pemphigus  vegetans  the  surface  of  the 
papUlary  outgrowths  is  excoriated  and  warty ;  in  a  syphilitic 
condyloma  the  surface  is  smooth  and  even.  A  ring  of  bullae 
round  the  papUlary  outgrowth  is  very  much  against  a 
diagnosis  of  syphilis.  In  all  doubtful  cases  a  Wassermann 
reaction  should  be  performed. 

XII.  Pityriasis  Rubra  (Exfoliative  Dermatitis).  This 
condition  may  be  primary  or  it  may  be  secondary  to  such 
pre-existing  skin  diseases  as  ezcema,  psoriasis,  or  lichen 
planus. 

The  onset  is  sudden  with  more  or  less  malaise,  shortly 
followed  by  the  appearance  of  symmetrical  red  patches 
any\\here  on  the  body.  These  patches  spread  with  great 
raj)idity  and  fuse  with  theu"  neighbours,  until  within  a  few 
h(jurs  the  entire  body  is  involved  from  head  to  foot. 

The  skin  is  bright  scarlet,  but  soon  becomes  covered  with 
thin,  papery  scales,  which  overlap  each  other  and  vary 
consitlerably  in  size.  There  is  no  crust  formation  and  but 
rarely  any  exudation,  though  sometimes  there  is  a  ceitain 
amount  of  perspiration.  There  is  little  or  no  itching. 
Desquamation  is  naturally  most  abundant. 

The  diagnosis  (accortliug  to  Monis)  (U'])eM(ls  upon  "'  the 
vivid  redness  of  the  eruption,  the  rapidity  ui  its  effusion    its 


G08  MEDICAL  DIAGNOSIS 

universality,  the  profuse  desquamation  with  papery  scales 
and  sheets,  the  frequent  absence  of  itching,  and  the  tendency 
for  there  to  be  serious  impairment  of  health  or  even  death."" 

XIII.  Pityriasis  Rosea.  This  condition  is  characterised 
by  the  occurrence  of  slightly  raised^  pink  patches  or  circles 
which  are  thinly  covered  with  small  scales. 

The  primary  patch  usually  appears  on  the  abdomen  ;  it 
spreads  at  its  edge  and  fades  at  its  centre,  and  in  about  a 
week  secondary  patches  develop  in  other  places. 

The  disease  spreads  rapidty  and  in  a  few  weeks  may  cover 
the  trunk  ;  the  forearms  and  legs  below  the  knee  usually 
escape. 

In  from  one  to  two  months  the  process  terminates  spon- 
taneously.    There  is  little  or  no  itching. 

Pityriasis  rosea  must  be  distinguished  from — 

Seborrhea  Corporishy  the  absence  of  the  initial  papules,  the 
distribution  and  rapid  spread  (seborrhoea  corporis  avoids  the 
limbs  and  prefers  the  back  of  the  trunk  to  the  front),  the 
dryness  of  the  scales,  and  the  absence  of  the  bottle  bacillus. 

Psoriasis  by  its  more  rapid  development,  different  dis- 
tribution, and  relatively  slight  scaliness. 

XIV.  Pityriasis  Rubra  Pilaris  (Lichen  Ruber  Acuminatus). 
The  characteristic  feature  is  the  development  of  small  hard, 
dry,  red,  conical  papules  at  the  orifices  of  hair  follicles. 
Each  papule  has  a  single  atrophic  hair  in  its  centre.  The 
papules  are  very  small  and  impart  a  definite  roughness 
to  the  skin.  They  are  most  abundant  on  the  backs  of  the 
fingers,  on  the  outer  side  of  the  forearms,  and  on  the  thighs 
and  buttocks — that  is  to  say,  where  there  is  most  hair. 
Itching  is  slight  or  absent. 

The  papules  tend  to  coalesce  to  form  pale  yellowish-red 
patches  covered  with  small  papery  scales. 

The  diagnosis  depends  upon  the  discovery  of  the  small 
conical  papules  with  the  smgle  hah  plugging  the  mouth  of  a 
follicle.     If  these  papules  are  pulled  off  small  pits  are  left. 

Lichen  planus  can  be  recognised  by  the  itching,  the  dis- 
tribution, the  flat  or  umbilicated  papule,  and  the  beneficial 
reaction  to  arsenic. 

XV.  Prurigo,  (a)  Simple  Prurigo.  Some  writers  con- 
sider  that   the  papular  rash   with  subsequent  roughening 


CERTAIN   DISEASES   OF   THE   SKIN  609 

of  the  skin  is  merely  the  reaction  to  scratching  in  a  case  of 
pruritus.  Most  authorities,  however,  consider  that  the 
eruption  is  an  essential  feature  of  the  disease. 

Simple  prurigo  may  develop  in  childhood,  but  is  more 
common  between  the  ages  of  20  and  30.  There  is  intense 
local  itching,  which  is  intermittent  and  which  is  followed  by 
the  development  of  a  crop  of  papules.  These  tend  to  group 
themselves  into  three  concentric  zones  and  then  form  \\'hat 
is  called  a  "  plaque."  Prurigo  generally  attacks  the  neck, 
the  thighs,  the  loins,  the  axillary  and  popliteal  folds,  the 
genitals,  or  the  palms  of  the  hands  and  the  soles  of  the  feet, 
but  any  part  may  be  affected.  Eventually  the  affected  skin 
beccmes  thickened  and  ^\Tinkled  (lichenification)  and  often 
assumes  a  brownish  tint.     Relapses  are  very  common. 

The  diagnosis  is  based  upon  the  extreme  itching,  Jhe 
long  duration,  the  character  of  the  papules,  and  the  licheni- 
fication. 

(h)  Hebras  Prurigo.  This  commences  in  the  first  year  of 
life  and  tends  to  persist  till  death.  The  characteristic 
feature  is  an  eruption  of  papules  on  the  extensor  aspects  of 
the  limbs  and  on  the  chest,  back,  abdomen,  and  buttocks. 

Itching  is  very  severe.  The  papules  are  at  first  of  the 
same  colour  as  the  skin,  but  after  they  have  been  scratched 
they  become  red  and  are  generally  surmounted  by  a  blood 
crust. 

The  lymphatic  glands  in  the  groins  and  axillai  are  nearly 
always  enlarged. 

Eventually  the  affected  skin,  especially  on  the  legs  and 
forearms,  acquires  a  roughness  which  gives  ahnost  the  sensa- 
tion of  touching  canvas. 

This  peculiar  feeling  of  the  skin,  together  with  the  papular 
rash  on  the  extensor  aspects  of  the  limbs,  the  age  of  onset, 
the  persistence  of  the  disease,  and  the  enlarged  lymphatic 
glands,  is  generally  sufficient  to  ensure  a  correct  diagnosis. 

X\'I.  Psoriasis.  This  disease  is  characterised  by  the 
occurrence  on  the  skin  of  dry  patches  which  are  covered  by 
shining  white  scales.  The  amount  of  the  scales  varies  form 
a  thin  hiyer  to  a  large  heaped-ii])  mass.  If  the  scales  (which 
are  quite  adherent)  are  pulled  olT  a  smooth  hypera?mic 
surface  is  left  on  which  are  dotted  a  vaiiable  number  of 

SI. I).  W.) 


610  MEDICAL   DIAGNOSIS 

deep-red    spots.     These    are    the    siinimits    of    congested 
papillae  and  bleed  readDy. 

The  individual  patches  are  sharply  circumscribed,  and 
even  when  they  are  actively  spreading  there  is  only  a  very 
narrow  zone  of  hypersemia  around  them.  As  the  patches 
fade  they  can  be  observed  to  clear  up  first  in  the  centres,  so 
that  ring  forms  with  a  gradually  diminishing  border  are 
common. 

Psoriasis  lasts  for  months  or  years,  but  often  clears  up 
completely  for  a  tmie,  only  to  recur  with  renewed  vigour 
later  on.  All  parts  of  the  body  may  be  affected,  but  the 
face  usually  escapes.  In  practically  every  instance  the 
disease  starts  on  the  tips  of  the  elbows  and  on  the  front  of  the 
knees  below  the  patellae.  The  extensor  aspects  of  the  limbs 
are  preferred  to  the  flexors,  and  the  lesions  are  nearly 
always  symmetrical. 

The  scalp  is  very  often  affected,  and  typical  lesions  on  the 
palms  and  soles  are  common.  The  nails  may  become 
involved,  and  even  pushed  out  of  their  beds,  as  the  psoriasis 
develops  in  the  matrix.     There  is  no  itching. 

Diagnosis.  This  depends  upon  the  site  of  origin  on  the 
elbows  and  knees,  the  preference  for  the  extensor  surfaces 
of  the  limbs,  the  silvery  scales,  the  sharp  border  of  the  lesions, 
the  absence  of  exudation,  and  the  chronicity. 

Eczema  weeps  sooner  or  later,  commences  as  vesicles, 
prefers  the  flexor  aspects,  has  no  well-defined  margin,  and 
tends  to  form  crusts. 

Lichen  Planus  prefers  the  flexor  surfaces,  has  no  scales 
like  those  of  psoriasis,  and  is  formed  by  an  aggregation  of 
multiple  bluish-red  papules,  whereas  psoriasis  is  formed  by 
the  peripheral  spreading  of  single  bright-red  papules  (the 
papules  are  bright-red  until  they  are  covered  up  by  the 
scales). 

Pityriasis    Rubra    develops    very    rapidly,    involves    the 
entire  body,  and  is  covered  by  thin  wafery  scales  through 
which  the  red  skin  is  clearly  seen. 
Pityriasis  Rosea  {vide  p.  608). 

Syphilis  may  cause  a  psoriasiform  eruption  identical  with 
true  psoriasis.  Other  signs  of  syphUis  must  be  sought  for, 
and  if  necessary  a  Wassermann  reaction  performed. 


CERTAIN   DISEASES    OF   THE   SKIX  611 

XVII.  Sycosis.  This  disease  is  due  to  a  skin  infection 
with  Staphylococcus  pj^ogenes  aureus  limited  to  the  hairy 
parts  of  the  face. 

The  essential  lesions  are  papules  which  form  round  the 
hairs  and  speedily  pustulate.  Each  pustule  is  pierced 
by  a  hair.  They  spread  rapidly,  but  never  advance  to  the 
non-hairy  parts.  The  pus  dries  into  adherent  yeUo wish- 
brown  crusts,  and  the  hairs  become  loose  as  their  follicles 
become  filled  with  pus,  but  baldness  does  not  follow.  There 
is  little  or  no  itching. 

The  diagnosis  rests  upon  an  obvious  inflammatory  lesion 
starting  in  the  hair  follicles  and  never  spreading  away  from 
the  hairy  parts. 

In  eczema  the  inflammation  is  less  acute,  the  follicles  are 
only  involved  secondarily,  and  the  process  is  not  linpted 
to  the  hairy  parts  ;  in  Tinea  barbce  the  primary  lesion  is  a 
round  red,  scaly  patch  (ringworm)  and  the  fungus  can  be 
discovered  in  the  affected  hairs. 

XVIII.  Urticaria.  This  condition  is  characterised  by  the 
appearance  of  wheals  on  the  skin  or  mucous  membranes. 
These  raised  areas  of  skin  are  at  first  bright  red  and  are 
often  surrounded  by  an  erythematous  border  ;  later  they 
become  white  and  anaemic  in  the  centre.  The  individual 
wheals  vary  greatly  in  size  ;  they  develop  quite  suddenly, 
itch  intensely,  and  last  from  a  few  minutes  to  a  few  hours  ; 
fresh  crops  may,  however,  appear,  and  the  whole  attack  may 
last  for  days,  months,  or  even  years. 

Any  part  of  the  skin  may  be  affected,  and  there  is  no 
tendency  towards  symmetrical  arrangement. 

Sometimes  the  individual  wheals  are  small  and  leave 
papules  as  they  subside  (lichen  urticatus  or  urticaria 
pa])nlosa),  sometimes  there  is  haemorrhage  into  the  wheals 
(purpura  urticans),  and  sometimes  bulla?  develop  on  the 
surface  of  the  wheals  (urticaria  bullosa). 

It  has  been  suggested  that  urticaria  is  due  to  over  suscepti- 
bility to  foreign  albuminoid  bodies  ;  certainly  it  is  produced 
very  readily  in  certain  ])eople  by  special  articles  of  diet. 

The  diagnosis  depends  upon  the  sudden  onset,  the 
characteristic  wheals,  and  the  rapid  subsidence  of  the 
individual  lesions. 

3U— 2 


612  MEDICAL   DIAGNOSIS 

XIX.  Certain  Drug  Eruptions.     (1)  Acetanilide.     A  slate - 
blue  discoloration  of  the  skin. 

(2)  Anti-toxin.     Erythema  and  urticaria. 

(3)  Arsenic.  Erythema,  urticaria,  eczema,  herpes  zoster 
and  keratosis. 

(4)  Belladonna.    Scarlatiniform,  erythemato-papular  rash. 

(5)  Borax.     Psoriasiform  eruption. 

(6)  Bromides.     Erythema,  urticaria,  or  acneiform  rash. 

(7)  Chloral  hydrate.     Erythema. 

(8)  Copaiba  and  similar  oleo-resins.  Erythematous 
patches  which  itch  severely. 

(9)  Digitalis.     Urticarial  or  papular  rash. 

(10)  Enemata.     Scarlatiniform  eruption. 

(11)  Iodide  or  iodoform.  Erythematous,  bullous,  purpuric, 
or  acneiform  rash. 

(12)  Opium.     Erythema  or  urticaria. 

(13)  Phenazone.  Erythema  or  papular  rash,  sometimes 
morbilliform. 

(14)  Quinine.  Scarlatiniform,  morbilliform,  or  urticarial 
rash. 

(15)  Salicylates.  Scarlatiniform,  morbilliform,  or  urti- 
carial rash. 

(16)  Santonin.     Urticaria  (and  xanthopsia). 

III.   CERTAIN  NEW  FORMATIONS. 

Innocent  growths  only  will  be  described.  For  a  descrip- 
tion of  malignant  disease  of  the  skin  the  student  is  referred 
to  text-books  of  Surgery  and  Pathology. 

I.  Corn  (Clavus).  A  corn  is  an  overgrowth  of  epidermis, 
produced  as  a  rule  by  pressure  irritation.  The  deeper  part 
of  the  corn  in  the  form  of  a  cone  presses  inwards  on  the 
corium,  which  may  become  inflamed.  Corns  may  be  hard 
or  soft,  according  as  to  whether  there  is  local  moisture  or 
not.  If  a  bursa  develops  underneath  a  corn  a  bunion  is 
produced. 

A  callosity  differs  from  a  corn  in  that  the  epidermal 
thickening  is  purely  superficial  and  there  is  no  core  pressing 
downwards  upon  the  corium. 

II.  Wart  (Verruca).     A  wart  is  produced  by  local  over- 


CERTAIN   DISEASES   OF   THE   SKIX  613 

growth  of  cutaneous  papillae.  Warts  are  the  result  of  chronic 
irritation  or  of  an  infective  process  {e.g.,  gonccoccus),  though 
the  nature  of  the  infection  is  in  many  cases  obscure. 

Warts  may  be  either  protuberant  or  flat  :  the  former 
variety  are  common  about  the  hands  and  fingers  ;  the  latter 
are  often  seen  on  the  forehead,  back,  shoulders,  and  on  the 
soles  of  the  feet  in  the  form  of  a  flat,  raised  surface  which 
looks  rather  like  a  callosity,  but  which  can  be  shown  to  have 
papillary  processes  extending  quite  deeply  into  the  true 
skin. 

III.  Cheioid.  A  cheloid  is  a  fibrous  tissue  overgrov/th 
originating  in  a  scar.  It  usually  appears  as  a  white  or  pinkish 
swelling  of  irregular  shape,  sometimes  with  a  depressed 
centre,  tending  to  extend  laterally  by  claw-like  processes. 
The  sternum,  trunk,  face,  and  head  are  the  most  usual  sites 
for  cheloid  growth. 

IV.  Fibroma,  (a)  Fibroma  Molluscum.  Multiple-rounded 
or  pyriform  sv.ellings,  softish  in  consistence,  usually 
pedunculated,  but  sometimes  sessile  and  covered  by  smooth 
skin.  They  vary  in  size  from  that  of  a  hemp-seed  to  that 
of  an  orange. 

(6)  Von  RecldingJiausen* s  Disease.  This  disease  is 
characterised  by  multiple  cutaneous  fibromas,  pigmentation 
of  the  skin  in  the  neighbourhood  of  the  tumours,  and  some- 
times by  diffuse  fibrous  tissue  overgrowth  in  the  nerves, 
especially  the  nerves  of  the  upper  extremity. 

The  cutaneous  fibromas  may  be  definitely  in  association 
with  various  nerve  trunks,  and  when  this  is  the  case  they 
are  composed  of  both  fibrous  and  nervous  tissues  (neuro- 
fibroma). Arthritis  deformans  and  papillary  tumours  are 
recorded  as  rare  manifestations  or  complications  of  von 
Recklinghausen's  disease. 

(c)  Hard  Fibromas.  These  tumours  usually  arise  in  the 
corium.  but  sometimes  in  the  nerve  sheaths.  They  are 
usually  miilti])k'.  grow  slowly,  and  may  reach  a  large  size. 

V.  Molluscum  Contagiosum.  The.se  tumours  are  rounded 
mothei-(.f-j)earl-likc'  growths  about  the  size  of  a  pea.  with  a 
(l('])ression  at  the  summit  in  which  there  is  a  small  liole 
leading  to  the  centre  of  the  tumour. 

^Molluscum  contagiosum  is  most  often  set  n  in  children  and 


614  MEDICAL  DIAGNOSIS 

on  the  eyelids  and  face,  but  the  neck,  limbs,  and  genitals 
may  also  be  affected. 

The  pathology  is  obscure  ;  under  certain  circumstances 
inoculation  experiments  have  been  successful,  so  that 
possibly  the  disease  is  infective.  Chickens  and  other  birds 
often  suffer  from  molluscum  contagiosum,  so  that  it  is 
conceivably  acquired  from  them  in  some  cases. 

The  diagnosis  is  easy  ;  if  necessary  the  grov/th  may  be 
squeezed  and  the  milk-white  fluid  v/hich  is  expressed  can  be 
examined  for  so-called  "molluscum  bodies,"  which  are  clear 
oval  bodies  the  result  of  degeneration  in  epithelial  cells. 

VI.  Xanthoma.  This  consists  in  the  formation  of  yellow- 
ish-white plates,  or  more  rarely  nodules,  which  are  imbedded 
in  the  corium. 

Xanthoma  usually  affects  the  upper  eyelid,  sometimes 
the  lower  eyelid  also,  and  more  rarely  the  skin  in  other 
parts,  or  even  the  mucous  membranes. 

The  formation  appears  to  consist  of  pigmented  skin 
overlying  a  loose  fibrous -tissue  reticulum  in  which  are 
imbedded  numerous  multi-nuclear  connective  tissue  cells 
filled  with  fat  droplets. 

Xanthoma  is  associated  with  diabetes  in  many  instances, 
but  may  be  a  congenital  or  familial  condition. 

The  diabetic  variety  differs  somewhat  from  the  other  forms 
in  that  the  tumours  are  red  at  first  and  there  is  a  predilec- 
tion for  their  development  on  the  extensor  surfaces  of  the 
forearms. 

VII.  Ichthyosis.  This  is  a  congenital  abnormalit}^  (often 
familial),  characterised  by  hypertrophy  of  the  papillary 
layers  of  the  skin  and  brittleness  of  the  epidermis,  Vv^hich 
cracks  in  a  lozenge-shaped  manner. 

In  mild  cases  dryness  and  roughness  of  the  skin  is  all  that 
can  be  noticed  (xerodermia)  ;  in  well-marked  cases  the  skin 
resembles  that  of  a  reptile. 

IV.  PARASITIC  AFFECTIONS  OF  THE  SKIN. 

A.  Diseases  due  to  Vegetable  Parasites. 
I.  Ringworm.     The  ringworm  fungus  maybe  large -spored 
or  small-spored.     The  former  has  two  principal  varieties — 


CERTAIN   DISEASES   OF   THE   SKIX  615 

Trychophyton  endo-  or  ecto-thrix — according  as  to  whether 
it  is  found  inside  or  outside  the  hairs  ;  the  latter  is  always 
outside  the  hairs. 

(a)  Ringworm  of  the  Scalp  (Tinea  tonsurans).  In  the 
great  majority  of  cases  in  England  this  is  due  to  the  small- 
spored  fungus  (microsporon  Audoumi) ;  sometimes,  however, 
the  Trychophyton  endothrix  is  the  cause.  Ringworm  of  the 
scalp  is  practically  confined  to  children,  and  is  very  rarely 
seen  after  the  age  of  puberty.  It  is  extremely  contagious. 
Clinically  it  first  manifests  itself  as  a  small  bare  spot  on  the 
scalp,  on  which  such  hairs  as  remain  are  broken,  bent,  and 
inelastic.     The  skm  is  often  scaly  and  reddened. 

The  diagnosis  can  be  made  with  certainty  by  pulling 
out  some  of  the  affected  hairs,  soaking  them  in  ether  to 
remove  grease,  and  examining  them  microscopicalh'  in  a 
drop  of  liquor  potassse.  The  small  spores  and  narrow 
mycelial  fragments  are  arranged  irregularly  around  the  hair. 

(6)  Kerion.  This  is  a  variety  of  ringworm  which  produces 
such  a  severe  inflammatory  reaction  in  the  hair  follicles  that 
the  affected  patch  becomes  swollen  and  boggy  and  the 
follicles  ooze  pus.  Kerion  is  due  to  infection  with  a  trycho- 
phyton. 

(c)  Ringworm  of  the  Body  (Tinea  Circinata).  Any  of  the 
ringworm  fungi  may  cause  an  infection  of  the  skin  of  the 
body,  but  an  endothrix  trychophyton  is  the  usual  cause. 

Circular  red  patches  develop  on  the  skin,  often  covered 
with  scales,  sometimes  with  vesicles  or  pustules.  They  tend 
to  heal  centrally,  so  that  ring  forms  are  produced. 

Th?  diagnosis  is  confirmed  by  the  demonstration  of  the 
fungus  or  by  the  rapidity  with  which  the  patches  disappear 
under  treatment. 

{(l)  Ringworm  of  the  Beard  (Tinea  barbae).  This  is  usually 
ciused  by  an  ectothrix  trychophyton  derived  from  the 
h')rse.  Th?  fir.st  sign  is  the  development  of  a  red  scaly 
])atch  ;  in  a  short  while  pustules  develop  in  the  hair  follicles 
on  this  patch,  while  other  similar  patches  form  Ic.cally  and 
become  confluent. 

The  condition  must  not  be  confounded  with  coccogenic 
sycosis  (vide-p.  611). 

(e)  Ringworm  of  the  Nails  (Tinea  Unguium).     This  is  a 


616  MEDICAL   DIAGNOSIS 

rare  and  obstinate  condition  and  always  due  to  a  trycho- 
phyton  derived  from  an  animal.  The  nails  become  thick, 
opaque,  and  brittle. 

II.  Favus  (Tinea  favosa).  The  fungus  of  this  disease  is 
the  achorion  Sehonleinii.  Children  are  the  chief  sufferers, 
but  amongst  lower  animals  mice  are  extremely  susceptible. 
The  fungus  nearly  always  attacks  the  scalp,  but  the  nails 
and  smooth  skin  may  be  affected. 

On  the  scalp  the  hair  follicles  are  picked  out  and  cup- 
shaped  crusts  of  sulphur-yellow  colour  are  formed  on  them. 
There  is  a  distinct  odour  of  mice. 

The  appearance  is  fairly  characteristic,  but  the  diagnosis 
can  be  made  certain  by  the  demonstration  of  the  spores  and 
mycelium  on  the  affected  hairs  and  in  the  epidermis. 

III.  Tinea  Versicolor.  This  is  due  to  the  presence  in  the 
cuticle  of  the  microsporon  furfur.  This  fungus  shows  itself 
by  the  formation  of  roundish,  slightly-raised  brown  scaly 
patches  on  the  trunk.  The  patches  are  extremely  super- 
ficial and  can  often  be  scraped  off  to  a  large  extent  with  the 
finger-nail.  There  is  little  or  no  itching  unless  the  patient 
sweats  a  great  deal. 

IV.  Erythrasma.  This  disease  is  produced  by  the  micro- 
sporon minutissimum.  It  forms  reddish-brown  patches,  not 
unlike  those  of  tinea  versicolor,  in  the  genito-crural  region. 
It  is  rare  in  England. 

B.  Animal  Parasites  of  the  Skin. 

I.  Acarus  Scabiei  (Sarcoptes  Hominis  :  Itch  Mite). 
Scabies  is  a  dermatitis  with  secondary  effects  from  scratch- 
ing and  sepsis.  The  cause  is  the  itch  mite,  or  rather  the 
female  itch  mite,  which  excites  the  dermatitis  while  making 
a  burrow  in  the  skin  in  which  to  lay  her  eggs. 

The  burrow  is  about  j  to  |  inch  long,  and  in  it  are  deposited 
about  fifty  eggs  in  the  course  of  two  months.  The  eggs 
take  a  week  to  hatch  and  then  the  embryos  crawl  out  of  the 
burrow  ;  the  male  parasite  does  not  live  in  the  burrow. 

The  female  is  larger  than  the  male,  being  just  visible  to  the 
naked  eye  as  a  whitish  speck  ;  she  has  a  circular  body  and 
eight  legs,  of  which  the  four  front  ones  have  suckers  and  the 
four  hind  ones  bristles.  The  two  median  hind  legs  of  the 
male  have  suckers  as  well  as  the  four  front  legs. 


CERTAIN   DISEASES   OF   THE   SKIX  617 

The  lesions  of  scabies  are  seen  chiefly  where  the  skin  is 
thinnest — that  is  to  say,  the  webs  of  the  fingers,  the  front 
of  the  A^Tists,  the  ankles,  genitals,  breasts,  etc. 

The  only  characteristic  lesions  are  the  burrows,  eachvvith 
a  vesicle  at  its  entrance,  and,  if  these  have  been  destroyed 
by  scratching,  a  linear  arrangement  of  the  scars  and  scabs. 

Apart  from  the  above  any  lesion  that  can  be  produced  by 
inflammatory  reaction  may  be  present. 

A  pustular  eruption  on  the  hands  should  always  arouse 
suspicion.  The  only  subjective  symptom  is  itching,  and 
this  is  intense. 

II.  Pediculus  Capitis  (the  Head  Louse).  This  is  an  oval 
insect  about  j\,  inch  long  with  six  clawed  legs.  The  male  has 
a  penis  on  its  back  and  the  posterior  end  of  the  female  is 
notched.     The  female  is  distinctly  larger  than  the  male. 

The  eggs  (nits)  are  deposited  on  the  hairs,  to  which  they 
are  tightly  adherent ;  they  can  be  seen  as  semi-transparent 
oval  bodies  sticking  to  the  hairs  ;  they  hatch  in  five  days. 

These  pediculi  live  by  sucking  the  blood,  and  the  irritation 
caused  by  this  and  by  their  perambulations  causes  the  only 
symptom,  namely,  itching.  Scratching,  with  secondary 
infection  of  the  lesions  so  produced,  may  result  in  an  exten- 
sive pus  infection  of  the  scalp.  Enlargement  of  the  lymphatic 
glands  in  the  posterior  triangles  of  the  neck  is  common. 

III.  Pedicuius  Vestimentorum  aut  Corporis  (the  Clothes 
Louse).  This  insect  is  longer  and  slimmer  than  the  head 
louse  ;  it  lives  in  the  folds  of  the  clothing,  especially  the 
neck-band  of  the  shirt,  and  there  the  female  lays  her  eggs, 
which  are  minute,  spherical  yellow  bodies. 

The  clothes  louse,  like  both  other  varieties  of  pediculus, 
lives  by  inserting  its  probo.scis  into  the  mouth  of  a  sweat 
gland  and  .sucking  blood  therefrom.  This  blood  suction 
causes  the  minute  htemorrhagic  points  which  are  so  charac- 
teristic of  ])e(liculosis. 

The  only  symptom  is  itching,  but,  of  course,  secondary 
(lermatilis  is  common. 

Va<jnh()}i<r.s  Disease,  a  })eciiliar  harshness  of  Ihe  skin  with 
more  or  less  deep  pigmentation,  is  probably  attributable  to 
])edieulosis.  dirt    and  other  ])arasites. 

IV.  Pediculus    Pubis    (the   Crab    Louse).     Tiiis   in.sect   is 


618  MEDICAL   DIAGNOSIS 

shorter  and  broader  than  either  of  those  just  mentioned — ■ 
indeed,  it  bears  a  distinct  resemblance  to  a  crab.  It  may 
occur  all  over  the  hairy  parts  of  the  body,  but  greatly 
prefers  the  pubic  region,  and  is  rarely  or  never  found  in  the 
scalp. 

The  ova  are  attached  to  the  hairs  close  to  the  skin.  Itching 
is  severe,  and  a  papular  (pruriginous)  eruption  is  not  un- 
common. 

Characteristic  patches  of  steel-grey  discoloration  (macule© 
cserulese)  are  seen  on  the  skin  of  persons  who  have  harboured 
pubic  pediculi  for  any  length  of  time.  These  are  thought 
to  be  due  to  a  colouring  matter  present  in  the  thorax  of  these 
lice,  which  is  presumably  injected  under  the  skin  during 
the  process  of  blood-sucking.  The  patches  soon  disappear 
when  the  parasites  are  destroyed. 


INDEX 


Abdomen,  distension  of   enteric, 
18 

in  tuberculosis,  100 
Abdominal  conditions    in    pneu- 
monia, 54 

tumours,  178 
Abscess,  cerebral,  causes  of,  529 

tropical,  388 
Acarus  scabiei,  616 
Acetone  in  urine,  189,  429 
Achondroplasia,  173,  194 
Acliylia  in  gastritis,  339 

in  stomach  cancer,  349 
Acidity  of  gastric  contents,  329, 

333 
Acidosis,  189,  326 

in  uraemia,  459 
Acne  rosacea,  596 
Acne  vulgaris,  595 
Acromegaly,  173,  181 
Actinomyces  hominis,  2 
Actinomycosis, 

alimentary  tract,  2 

cerebral,  3 

cutaneous,  3 

diagnosis  of,  1 

resjiiratory,  2 
Addison's  disease, 

differential  diagnosis  of,  176 

signs  and  symj)toms  of,  176 
Adenitis,    secondary    carcinoma- 
tous, 102 

septic,  102 
yEgophony,  280 

^Estivo-autumnal  fever,  126,  129 
Air-hnngci',  274 
Air-swallowing,  hysterical,  588 
Albinism,  592 
Albumin,  ])resence  of,  causes,  418 

(piaiititative  determination, 
421 

lesls  for,  419,  422 
Albuminuria,  clinical,  418 

in  diabetes,  I8S 

in  whooping-cougli,  115 
Albumoses  in  urine,  422 


Alcoholic    poisoning,  acute,  200, 
460 

Alcoholism,  200,  520 
acute,  200,  460 
chronic,  201 

digestive  system  in,  201 
mental  svmptoms,  201 
gastritis  due  to,  326,  337,  338 
neuritis  due  to,  508 

Alimentary  tract, 
actinomycosis,  2 
tuberculosis  of,  98  ' 

Alopecia,  593 
areata,  593 
in  secondary  syphilis,  71 

Amaurosis,  443 

Ammonia  nitrogen  in  urine,  413 

Ammonio-magnesium  i)hosphate, 
crystals  of,  430 

Amoeba  dysenterite,  121 

Amyotonia  congenita,  565 

Ansemia,  blood  in,  158,  160 
from  htemorrhage,  160 
idiopathic  (of  Addison),  162 
in  lead  poisoning,  204 

Ansemia,  pernicious,  162 
aplastic  type  of,  163 
blood  in,  163 
diagnosis  of,  163 
symptoms  and  signs  in,  162 

Anaemia,  splenic,  168 

Anaesthesia  in  hysteria,  587 

Aneurysm,  aortic,  321 
abdominal,  268 
asceniling  portion,  267 
differential  diagnosis,  269 
inlrajM-ricardial  ])ortion,  267 
of  descending  arch,  2(58 
of  transverse  aicli,  268 
]thys;eal  signs  of,  265 
l)ressur(^  from,  2()5 
pulse,  inetiuality  in,  266 
symi>tomatology  of,  264 
tiioraric,  268 
tracheal  tug  in,  266 
visible  pulsation  in,  265 


620 


INDEX 


Aneurysm,  intracranial,  514 

thoracic,  269 
Angina  pectoris,  257 
Angio-neurotic  oedema,  583 
Anidrosis,  595 
Animal  parasites,  140,  150 
Aukylostoma  dnodenale,  146 
Anorexia  nervosa,  321,  35l»,  588 
Anthrax,  diagnosis  of,  3 

incubation  period,  3 

malignant  pustule,  3 

splenic  fever,  4 

varieties  of,  4 

wool-sorters'  disease,  4 
Anuria,  causes  of,  457 
Aortic  aneurysm,  264,  270,  321 

reflu\-,  23:) 

regurgitation,  270 

valvedisease,  215,  260 
Aphasia,  motor,  524,  532 

sensory,  530 
Apoplexy,  causes  of,  515,  518 

pulmonary,  226 

spinal,  533 
Ajipendicitis,  362 

differential  diagnosis  of,  24 
Appetite,  disordered,  351 
Apraxia,  532 
Argyll- Robertson   reaction,   545, 

549 
Argyria,  177 
Arm  tics,  581 
Arsenical  iDoisoning,  177 

acute,  205 

chronic,  205 

diagnosis  of,  205 

symptoms  of,  205,  509 
Arteries,  cerebral,  479 

thrombosis  of,  517 

syphilitic,  disease  of,  71 
Arterio-sclerosis,  186 

cerebral,  514,  517 

forms  of,  263 

in  diabetes,  188 

manifestations  of,  264 
Arthritis,  differential     diagnosis 
of,  60 

gonorrhceal,  33 

in  pneumonia,  49 

rheumatoid,  195 
acute,  60 

scarlatinal,  60,  63 

septic,  191 
Arthritis  deformans,  195 

varieties  of,  196 
Ascaris  lumbricoides,  143 


Ascites,  differential 

diagnosis,  373 

positive  diagTiosis,  371 
Asphyxia,  local,  282 
Aspiration,  methods  of,  309 
Asthma,  bronchial,  302 

cardiac,  304 

renal,  304 

thymic,  303 
Ataxy,  cerebellar,  564 

locomotor,  543 
Atheroma,  71 
Athero-scleroriis,  263 
Athetosis,  post-paraplegic,  519 
Attitude  in  paralysis  agitans,  569 
Aura,  epileptic,  575,  577 
Auricular  fibrillation, 

clinical  features,  251 

diagnosis  of,  252 

prognosis  of,  253 
Auricular  flutter,  diagnosis,  250 

symptoms,  251 
Auscultation  of  chest,  278 

in  pleurisy,  312 

in  pneumonia,  46 

in  tuberculosis,  95 
Automatism,  epileptic,  576 


Bacilluria,  23,  439,  465 
Bacillus  authracis,  4 

coli  infection,  455 

diphtheriae,  11 

mallei,  31 

pestis,  134 

recovery  of  from  blood,  faeces 
and  urine,  23 

tetani,  78 

typhosus,  21 
Bacteriology  of  blood,  23,  158 

of  broncho -pneumonia,  298 

of  cholera,  117 

of  dysentery,  121 

of  gonorrhoea,  34 

of  leprosy,  124 

of  lobar  pneumonia,  43 

of  Malta  fever,  132 

of  measles,  38 

of  Mediterranean  fever,  132 

of  mumps,  42 

of  plague,  133 

of  pleural  effusion,  310 

of  relapsing  fever,  55 

of  rheumatic  fever,  56 

of  scarlet  fever,  61 

of  small-pox,  66 


INDEX 


021 


Bacteriology  of  stomach,  331 

of  syphilis,  69 

of  tetanus,  78 

of  tuberculosis,  81 

of  typhus.  Ill 

of  the  urine,  23,  439 

of  whooping-cough,  113 
Bence-Jones'  body  in  urine,  423 
Beri-beri,  IIG 

classes  of,  117 
Bile  passages,  diseases  of,  380 

pigments  and  acids  in  urine, 
410,  417 

secretion  of,  381 
Bilharzia,  embryos  of,  149 
BiUiarzia  h-iematobium,  440 
Bilharziosis,  150 
Biliary  cirrhosis,  392 
Birth  palsies,  522 
Bismuth  meal,  diagnostic,  357 
Blackwater  fever,  131,  424 

differential  diagnosis  of,  138 
Bladder,  inflammation  of,  465 

tuberculosis  of,  104 
Blood,  abnormal  number  of  red 
cells  and  hajmoglobin  in, 
158 

abnormal  number  of    white 
cells  in,  159 

abnormalities  of,  158 

bacteriology  of,  158 

colour  index  of,  152 

count  in  enteric  fever,  19 

cryoscopic  determination  of, 
464 

culture  experiment,  157 

enumeration  of  cells  in,  153 

estimation    of     amount    of 
hicmoglobin  in,  156 

estimation  of  white  cells  in, 
155 

examination  of,  151 

granular  cells  in,  151 

in  leukicmia,  164,  166 

in  pneumonia,  51 

in  urine,  410,  423 

megaloblastic,  163 

noji-graiiuhir  cells  in,  152 

occult,  test,  331 

red  cells,  causes  of  increased 
number,  159 

supply  in  brain,  478 

white    cells,   causes    of    in- 
creased number,  159 
Blood-]»ressure,  221 
Boas-(Jl)pler  bacillus,  331 


Bone,  abscesses  of,  enteric,  19 

changes  in,  in  rickets,  194 
svplnlitic    disease    of,   71, 
73 
Bothriocephalus  latus,  141 
Bougies,  oesophageal,  passing  of, 

321 
Bradycardia  in  influenza,  37 
Brain,  abscess  of,  causes  of,  528 
mental     conditions    in, 

529 
symptoms,  of,  529 
actinomycosis  of,  3 
anaemia  of,  local,  521 
blood  supply  of,  478 
compression  of,  515 
diseases  of,  513 
embolism  of,  517 
functions     of,     localisation, 

530,  532 
haemorrhage  in,  514 
lesions  of,  evidence,  48 1' 
palsies  of  infancy,  521,  522 
rheumatism  of,  58 
thrombosis  of,  516 
tumours  of, 

frontal,  524 
localising  signs,  524 
mid-brain,  526 
motor  area,  525 
occipital  region,  525 
sensory  area,  525 
symptoms,  523 
temporo-s  p  h  e  n  o  i  d  a  1 
lobe,  525 
vascular  lesions,  514 
Breath  sounds,  278,  280 
Breathing,  amjihoric,  279 
bronchial,  279 
broncho-vesicular,  279 
cavernous,  279 
harsh,  280 
tubular,  279 
vesicular  sound,  278 
Bright's  disease,  167,  177 
Bromidrosis,  595 
Bronchial  breathing,  279 

glands,  tuberculosis  of,  101 
Bronchiectasis,  acute,  291 
causes  of,  291 
chronic,  292 

differential  diagnosis,  293 

physical  signs,  292  *-• 

Bronchitis,  acute,  course  of,  287 

diagnosis  of,  287 

prognosis  of,  286 


622 


INDEX 


Bronchitis,  acute,  signs  and  sy in - 
l)toms  of,  287 

capillarv,  297,  299 

chronic,  291,  293 

diagnosis  of,  288 

in  influenza,  36,  38 

in  measles,  40 

in  rickets,  194 

unilateral,  288 
Bronchophony,  280 
Broncho-pneumonia, 

bacteriology  of,  298 

causes  of,  297 

differential  diagnosis,  300 

in  diphtheria,  12 

physical  signs  of,  299 
Bruit  de  diable,  161 
Bruit  de  pot  fele,  277 
Bubonic  plague,  133,  134 
Bulimia,  351 
Bulla,  definition  of,  592 
Butchers,  anthrax  in,  3 


Caisson  disease,  538 
Calculus,  urinary,  456 
CaUosity,  612 

Calmette's    Ophthalmo-Tubercu- 
lin   reaction    in    diagnosis    of 
tuberculosis,  107 
Cammidge's  test,  403 
Cancer  of  larynx,  89 

of   stomach,   163,   170,   338, 
347 
Canities,  593 
Carbohydrates,  185 
Carpo-pedal  spasm,  572 
Casts  in  urine,  436,  438 
Catalepsy,  586 

Cells,  blood,  enumeration  of,  153 
estimation    of    relative 

number  of,  155 
granular,  151 
non-granular,  152 
red,  i58 
in  urine,  434 

of  pleural  effusion  fluid,  310 
CeUulitis,  191 

in  erysipelas,  25 
Cerebellar  ataxia,  564 
Cerebello-i)ontine  angle,  tumours 

of,  528 
Cerebellum,  473 

haemorrhage  in,  516 
tumours  of  lateral  lobe,  526 
of  middle  lobe,  527 


Cerebellum,   tumours   of,  motor 
symptoms,  527 
reflexes,  527 
Cerebro-spinal  meningitis.        See 
under  Meningitis. 

syifliilis,  541 
Cestoda,  140 

Chancres,  syphihtic,  69,  74 
Cheeks,  diseases  of,  315 
Cheiropompholyx,  596 
Cheloid,  613 
Chest,  anatomy  of,  271 

auscultation  of,  278 

deformities  of,  272,  273 

expansion  of,  274 

inspection  of,  93,  272,  273 

palpation  of,  275 

percussion  of,  276 

physical     signs     of     lobar- 
pueumonia,  46 
Cheyne-Stokes  respiration,  275 
Chicken-pox,  diagnosis  of,  7 

differential  diagnosis,  8 

incubation  period,  7 
Chilblain,  600 
Children,    muscular    dystrophies 

in,  521,  560 
Chloasma,  593 

uterinum,  177 
Chlorosis,  161 

blood  in,  161 

complications  in,  161 

diagnosis  of,  161 

symptoms  and  signs  of,  161 
Cholangitis,  399 
Cholecystitis,  399 
Cholera,  atypical  forms  of,  119 

bacteriology  of,  117 

course  of,  118 

differential  diagnosis  of ,  120, 
123 

incubation  period  in,  118 

spu'Ulum  of,  118 
Cholesterin,  crystals  of,  434 

in  urine,  433 
Chorea,  570,  581 

Huntingdon's,  564 

in  rheumatism,  58 
Choroiditis,      disseminated,      in 

syphilis,  74 
Chvostek's  sign,  572 
Claudication,  intermittent,  582 
Clavus  hystericus,  587 
(  lonus,  eliciting,  477 
Cocaine  habit,  204 
Cceliac  disease,  366 


INDEX 


623 


Colic,  diagnosis  of,  360,  397,  399, 
457 
in  lead  poisoning,  204 
Colitis,  mucous,  368 
ulcerative,  367 
Colon,  idiopathic  dilatation  of,  367 
in  relation  to  renal  growths, 
462 
Colwell  and  MacCormack  occult 

blood  test,  331 
Coma  in    cerebral    haemorrhage, 
515 
in  diabetes,  188 
Comedo,  593 

Conjunctiva,  diphtheria  of,  10 
Conjunctivitis,  gonorrhoeal,  33 

in  small-pox,  68 
Constipation,  chronic,  tongue  in, 
314 
forms  of,  356.  358 
Convulsions  in  whooping-cough, 

114 
Convulsive  tics,  581 
Copaiba,  rashes  from,  41 
Corns,  612 
Cortical  degeneration,  bilateral, 

570 
Coryza,  chronic,  32 
Cough,  cause  of  emphysema,  289 
classification  and   types  of, 

281 
induced   by  pleural   lesions, 

281 
in  lobar  pneumonia,  45 
in  mediastinal  tumour,    295 
persistent     in    tuberculosis, 
92,  97 
Coup  de  soleil,  199 
Cratt  palsies,  573 
Cramj)  in  diabetes,  188 
Cramps,  occupation,  573 
Cranial      nerves.        See      under 

Nerves. 
Crepitations,  281 
Cretinism,  diagnosis  of,  173 

signs  and  symptoms  of,  173 
Cryoscopic      determination      of 

blood  and  urine,  464 
Crystalline     deposits     in    urine, 

431 
Cystin,  crystals  of,  433 

in  urine,  433 
Cystitis,  a-ute,  466 

l)a<"t<'ri()l<)gy  of,  465 
chronic.  466 
diagnosis  of,  466 


Cystoscopic  examinations,  103 
Cvstoscopy,  simple,  465 
Cysts,  372 
Cytoryctes  variolce,  66 


Deafxe-SS  in  syphilis,  74 

nerve,  5i»] 
Delirium  tremens,  202 

differential  diagnosis  of,  52 
Dementia  in  epUepsy,  577 

prsecox,  590 
Dermatitis,  exfoliative,  607 

herpetiformis,  602 
Diabetes  in.sipidus,  189 
Diabetes  mellitus, 

cardinal  symjttoms  of,  187 
clinical,  186 
diagnosis  of,  188 
etiology  of,  185 
prognosis  of,  189 
theories  as  to  cause,  1^7 
tongue  in,  314 
urine  in,  188 
Diacetic  acid  in  urine,  431 
Diaphragm,  action  of,  274 
Diarrlia?a,  causes  of,  354 

indications  of,  353 
Diet,  gastritis  due  to  errors  in, 

337 
Dietl's  crisis,  457 
Differential  diagnosis 

of  acute  specific  fevers,  51 

of  Addison's  disease,  177 

of  anthrax,  4 

of  aortic  aneurysm,  269 

of  appendicitis,  24 

of  arthritis,  60 

of  ascites,  373 

of  blackwater  fever,  138 

of  bronchiectasis,  293 

of  broncho -pneumonia,  300 

of  cerebro-spinal  meningitis, 

68 
of  chicken-pox,  8 
of  cholera,  120,  123 
of  colla])sed  lung,  53,  308 
of  delirium  tremens,  52 
of  di.><.s»'minated  sclerosis, 

r)52,  554 
of  drug  rashes,  41,  65 
of  cczcnia,  59S 
of  eiiil)()lisni,  226 
of  enteric  fever,  7,  84,   112, 

122 
of  epilepsy,  577 


624 


INDEX 


Differential  diaonosis — conid. 
of  erythema  multiforme,  41 
of  follicular  tonsillitis,  14,  65 
of  food  poisoning,  27 
of  gastric  diseases,  338 
of  gastric  ulcer,  342 
of  German  measles,  27,  41, 

64 
of  gout,  60,  191 
of  hemiplegia,  519 
of  hydrothorax,  308 
of  hysteria,  577 
of  influenza,  24,  38 
of  laryngeal  tuberculosis,  88 
of  lobar  pneumonia,  24 
of  malaria,  24, 120, 123,  226 
of  measles,  113 
of  multilobular    cirrhosis    of 

the  liver,  392 
of  mumps,  43 
of  nervous  diseases,  547,  549, 

5i52,  f55 
of  oesophageal     obstruction, 

321 
of  para-typhoid  infection,  24 
of  pemphigus,  606,  607 
of  pericarditis,  acute,  300 
of  pleural  effusion,  52,  308 

empyema,  300 
of  pleurisy,  52 
of  pneumonia,  7,  51 
of  psoriasis,  610 
of  pulmonary  diseases,  51,  53 
of  rheumatic  fever,  60 
of  scarlet  fever,  41,  64 
of  septicaemia,  23 
of  skin  diseases,  598,  610 
of  small  pox,  41,  65,  68,  113 
of  spinal  tumours,  539  \ 
of  splenic  enlargements.  179 
of  tuberculosis,  23,  84,  226 
of  ulcerative  endocarditis,  23 
of  ulcer  of  stomach,  342 
of  uraemia,  460 
of  yellow   ever,  138 
Diphtheria,  acute  nephritis  in,  13 
antitoxin  treatment  of,  9 
broncho-pneumonia  in,  12 
complications  of,  11 
conjunctival,  10 
course  of,  9 
diagnosis  of,  13 
differential  diagnosis,  14,  64 
etiology  of,  9 
faucial,  10 
heart  failure  in,  11 


Dijihtheria,  incubation  period,  9 
nasal,  10 

otitis  media  in,  12 
post-diphtheritic      paralysis 

of,  12 
varieties  of,  10 
Diplegia,  cerebral,  congenital,  521 
Diplococcus  intracellularis,  5 

pneumoniae,  44 
Distal    type    of    muscular    dys- 
trophy, 562 
Distoma,  149 
Diver's  paralysis,  538 
Doremus'  ureometer,  412 
Drug  eruptions,  28,  612 

rashes,      differential      diag- 
nosis of,  41,  65 
Drugs  in  urine,  410 
Dum-dum  fever,  clinical  features 
of,  123 
diagnosis  of,  124 
Duodenum,  catarrhal  affections, 
361 
ulcer  of,  343 

differential      diagnosis, 

362 
signs     and    symptoms, 
361 
Dust,  cause  of  fibrosis  of  lungs, 

294 
Dysentery,  bacteriology  of,  121 
differential  diagnosis  of,  122 
symptoms  of,  122 
Dyspepsia,   344 
Dyspnoea,  274 

in  tuberculosis,  94 
Dyspituitarism,  182 
Dystrophies,  muscular,  560,  562 


Eberth's  bacillus,  14 
Echinococcus,  440 
Eczema,  596,  610 

description  of,  597 

differential  diagnosis,  598 

seborrhoeic,  598 
Ehrlich's    Diazo-reaction   in   en- 
teric fever,  19 
Electrical     reactions     in     myas- 
thenia gravis,  567 
Electrocardiograph,  238 
Embolism,  cerebral,  226,  517 

differential  diagnosis,  226 

in  endocarditis,  224 

pulmonary,  224 
Emphysema,  compensatory,  290 


INDEX 


625 


Emphysema,  diagnosis  of,  290 
hypertrophic,  290 
interstitial,  291 
small-lunged  or  atrophic.  290 
Empyema,  clinical  features,  308 
differential  diagnosis  of,  53 
loculated,  309 
pleural,     differential      diag- 
nosis, 300 
in  pneumonia,  49 
Encephalitis,  symptoms  of,  522 
Endarteritis  obliterans,  71 
Endocarditis,  acute  simple,  59 
causes  of,  222 
rheumatic,  59 
symptoms  of,  223 
chronic,  227 

ulcerative,  differential  diag- 
nosis of,  23 
in  pneumonia,  49 
signs    and    symptoms, 
224 
Enteric  febricula,  17 

fever,  ambulatory,  16 
blood  count  in,  19 
complications       of, 

17,  19 
course  of,  15,  17 
diagnosis  of,  19 
differential    diagno- 
sis of,  23,  84,112, 
122 
Ehrlich's     Diazo- 

reaction,  19 
incubation     period, 

15 
intestinal      compli- 
cations, 17 
nephritic,  17,  18 
nervous     complica- 
tions of,  18 
rash  in, 16 
relapses  in,  16 
tongue  in,  314 
varieties  of,  16 
Widal's  reaction  in, 
20 
Enteritis,  acute,  causes  of,  363 
symptoms  of,  364 
•'Itidi'iuic,  364 
Eosiii(»pliili;i.  143 
EplM'lis  ah  igiic,  592 
Epilepsv.  aura  varieties  in,  575, 
577 
clinical  divisions,  574 
differential  diagnosis,  577 

M.D, 


Epilepsy,  Jacksonian,  574 

major,  575,  577 

minor,  576,  578 

nocturnal,  576,  578 

psychical  phenomena,  576 

relationship  to  migraine,  279 

status  epilepticus,  576 
Ephitelioma,  315 
Erb's  juvenile  type  of  muscular 

dystrophy,  561 
Erysipelas,  course  of,  25 

complications  of,  26 

diagnosis  of,  25 

incubation  period  of,  24 

varieties  of,  25 
Erythema,  599 

definition  of,  592 

tugax, 599 

intertrigo,  599 

iris,  601 

multiforme,  600 

differential  diagnosisA)f, 
41 

nodosum,  601 

paratrimma,  600 

pernio,  600 

scarlatiniforme,  65,  602 

simplex,  599 
Erythrasma,  616 
Erythromelalgia,  583 
Esbach's  method,  421 
Exhaustion,  syncope  from,  199 
Exophthalmic  goitre,  177 

complications  of,  174 

diagnosis  of,  175 

signs  and  symptoms  of,  174 
Ewald's  test  breakfast,  328 
Eye,  in  diabetes,  187 
in  gout,  192 
paralyses,  A91 


Facial  hemiatrophy,  583 

paralysis,  498 

tics,  580 
Facies  in  myasthenia  gravis,  567 
Facio  -  sca])ulo  -  humeral  type  of 

dystrophy,  561,  567 
Fa'ccs,  cxaiiiination  of,  23,  351 
Fainting  fits,  576,  578 
Familial  disea^sos,  56(t,  565 

spastic   para])legia,    564 
Family  idiocy,  amaurotic.  564 
Farcy,  acute  and  chronic,  30 
Fat  destruction  in  <liabetes,  18Q 
Fatigue  in  tuberculosis,  92 


40 


626 


INDEX 


Fauces,  diphtheria  of,  10 

Faviis,  616 

Fehlins's  solution,  reduction  of, 

427" 
Fermentation  test,  427 
Fever  in  tuberculosis,  94 
Fevers,  specific,  differential  diag- 
nosis, 51 
tongue  in,  314 
Fibroma  molluscum,  613 
Fibromas,  hard,  613 
Fibrositis,  197 

clinical  features,  198 
Filaria  Bancrofti,  embryos  of,  147 
mediueusis,  148 
sanguinis  hominum,  441 
Filariasis,  146 

clinical  manifestations,  148 
Fingers,  clubbing  of,  292 
Fischer's  test  meal,  328 
Flukes,,  149 

Fluoroscope  in  diagnosis,  269,  270 
Food  poisoning,  120,  363 

differential  diagnosis  of,  27 
Foreign    bodies    in    esophagus, 

320,  322 
Freckles,  592 

Friedlander's  pneumo-bacillus,  44 
Friedreich's  disease,  548,  563 
Functional  diseases,  574,  581 


Gait  in  cerebellar  ataxia,  564 
in  Friedreich's  disease,  563 
in  muscular  dystrophies,  560 
in  paralysis  agitans,  569 
in  tabes  dorsalis,  545 
Gall-bladder  in  relation  to  renal 

growths,  462 
Gall  stones,  362,  396 

diagnosis  of,  362,  399 
symptoms  of,  397 
Gangrene,  local,  582 
of  lung,  302 

pulmonary,    in    pneumonia, 
48 
Gangrenous  dermatitis,  8 
Gastrectasis,  atonic,  339 
obstructive,  344 
symptoms  of,  343 
Gastritis,  acute,  336 
atrophic,  339 
chronic,  323,  337,  362 
tongue  in,  314 
vomiting  in,  326 
clinical  varieties  of,  335 


Gastritis,    differential   diagnosis 
of,  338 

phlegmonous,  acute,  336 

toxic,  337 
Gastro-intestinal    symptoms    of 

influenza,  36 
Gastrostasis,  diagnosis  of,  342 
General  paralysis  of  insane,  590 

diagnosis  of,  549 

juvenile,  550 

mental  symptoms  in,  548 

motor  system  in,  549 

pupil  changes  in,  549 

reflex  system  in,  549 
Gerhardt's  test,  431 
German  measles,  41 

course  of,  27 

differential  diagnosis,  27,  41, 
64 

incubation  period,  27 
Gerrard's  ureometer,  412 
Giemsa's  staining  method,  155 
Girdle  pains  in  aneurysm,  270 

in  tabes  dorsalis,  545, 547 
Glanders,  acute  and  chronic,  30, 
31 

course  of,  30 

diagnosis  of,  31,  32 

incubation  period,  30 

varieties  of,  30 
Glands,  lymphadenoma  of,  169 

tuberculosis  of,  101 
Globulins,  422 
Glosso -pharyngeal      and     vagus 

nerve,  502 
Glottis,  ojdema  of,  25 
Glycogen,  186 
Glycosuria,  186,  426 

causes  of,  426 
Goitre,  endemic,  175 

exophthalmic,  174,  177 
Gonococcus,  34 
Gonorrhoea,  arthritis  in,  33 

bacteriology  of,  34 

diagnosis  of,  33 

manifestations  of,  32 

neuritis  in,  34 

ocular  comj)lications,  33 
Gout,  190 

acute,  191 

chronic,  192 

clinical  features  of,  191 

differential  diagnosis  of,  60, 
191 

etiology  of,  190 

metastatic,  192 


INDEX 


62: 


Graef,     See  V"on  Graef. 
Graves'  Disease,  174 
Grocco's  triangle,  307 
Guaiacam  and  ozonic  ether  test, 

424 
Guinea  worm,  148 
Gummata,  71,  74 

hepatic,  72 

laryngeal,  72 

of  lung,  72 
Gums,  diseases  of,  315 

in  lead  poisoning,  204 
Gunzberg's  test,  329 


Habit  spasms,  o71,  580 
Hsematemesis^  characteristics  of 
blood  in,  284 

in  gastric  disease,  342 
Haematomyelia,  533 
Hsematoporphyrin,  409 
Hfematuria,  causes  of,  423 
Haimoglohin,  158 

estimation  of,  156 
Ilsemoglobinuria,  131,  424 

paroxysmal,  582 
Haimoj)hilia,  170 
Hajmoptvsis,  character  of  blood 
in',  283 

in  tuberculosis,  92 
Ihemorihage,  an;einia  after,  160 

cerebellar,  516 

cerebral,  514 

intestinal,   in   enteric   fever, 
17 

in  kala-azar,  124 

]>()ntiii(',  516 

in  whooping  cough,  114 
lliemosidcrin,  de])osits  of,  162 
Hair,  disorders  of,  5f)3 
Ilaldane's       ha-moglobiiuimcter, 

1 56 
Hairison's  sulcus,  273 
Hayom's  solution,  153 
Headache.  184 

in  brain  tumour,  523 

in  inilucn/.a,  37 

periodic,  578,  580 
Heart,  alterations  in  dulness,  210 

auricles   of,  enlargement  of, 
211 

anatomy  of,  2i>7 

auricular  tibrillat ion,  251 
flutter,  249 

beat,  irregidaritv,  238,  253 

block.  24  1.  251  " 


Heart,  congenital  disease, 
lesions  in,  255 
symptoms  of,  256 
degenerations  of,  236 
dilation    of,  signs    and  sym- 
ptoms, 236  ' 
displacement  of  apex   beat, 
209 

inpleurisv,  306,  307,312 
enteric  comjjlications  of,  18 
failure  in  diphtheria,  11 
hypertrophy  of, 
causes  of,  234 
physical  signs  of,  235 
im])ulse,  alteration  in  charac- 
ter, 209 
in  pericarditis,  259 
irregularities  of  rhythm,  238, 

240,  253 
murmurs, 

aortic    reflux    and  /ste- 
nosis, 215 
arterial,  216 
double  or  multiple,  216 
functional,  213 
mitral    reflux    and   ste- 
nosis, 215 
organic,  214 
pulmonary    reflux    and 

stenosis,  216 
tricuspid  reflux  and  ste- 
nosis, 216 
venous,  217 
normal,  207 
physiology  of,  208 
premature  contractions, 

auricular  and  ventricu- 
lar, 244,  246 
clinical  diagnosis  of,  246 
rheumatic  affections  of,   57, 

59 
scarlet  fever  and,  63 
sounds, 

alterations    in    s])acing, 

212 
exocardial,  217 
tlirills,  significance   of,   213, 

217 
valvular  diseases,  212,  227 
adherent      pericardium 

and,  202 
aortic  reflux  and  steno- 
sis. 230.  232 
mitral  reflux  and  steno- 
sis. 212.  228 
])l.ysical  signs.  228.  231 

4U— 2 


628 


INDEX 


Heart,  valvular  diseases,  pulmo- 
nary reflux,  233 
pulse  in,  231 
tricuspid     reflux      and 
stenosis,  233 
ventricles    of,    livpertrophy 
of,  209,  211 
Heart-block,  causes  of,  241 

clinical  diagnosis,  242,  244, 
251 
Heberden's  nodes,  197 
Hebra's  prurigo,  609 
Heller's  test  for  albumin,  421 
Hemiansestliesia  in  hysteria,  587 
Hemianopia,  579 

bi-temporal,  184 
Hemiplegia,   clinical    manifesta- 
tions, 518 
differential  diagnosis  of,  519 
double,  570 

extent  of  paralysis  in,  519 
liysterical,  586 
Hereditary  nervous  diseases,  564 
Heredity  in  disease,  170,  172 
Hernia,  diapbragmatic,  313 
Herpes  facialis,  602 
genitalis,  602 
zoster,  602 

distribution  of  vesicles, 
9 
Hirschsprung's  disease,  367 
Hodgkin's  disease,  169 
Hoffmann's  bacillus,  13 
Hookworm  disease,  146 
Hormones,  186 
Horses,  glanders  in,  32 
Huntingdon's  chorea,  564 
Hutchinson's  teeth  in  congenital 

syphilis,  73 
Hyaline  cells,  152 
Hydatid   cyst,  booklets  in  fluid 
of,  142 
disease,  diagnosis  of,  143, 288 
simulating  ascites,  372 
Hydrocephalus,  acquired      type, 
513 
congenital  type,  513 
secondary,  514 
Hydrochloric  acid,  free,  325,  329, 
333 
estimation  of,  330 
Hydronephroma,  463 
Hydronephrosis,  462 
Hydrophobia,  course  of,  28 
diagnosis  of,  29 
incubation  period,  28 


Hydrophobia  mistaken  for  teta- 
nus, 29 
Hydrothorax,    differential    diag- 
nosis of,  308 
Hyperglycsemia,  185 
Hyperidrosis,  595 
Hvper-pituitarism,  symptoms  of, 

^183 
Hyperpyrexia  in  rheumatism,  58 
Hypersecretion,  gastric,  349 
Hypoglossal  nerve,  503 
Hysteria,  80,  567 

affections  of  cranial  nerves, 

586 
anfesthesia  in,  587 
differential    diagnosis,    377, 

577 
major  attacks,  585 
minor  attacks,  585 
motor  signs,  586 
reflexes  in,  587 
sensory    manifestations    of, 

587 
special  manifestations  in,  588 
Hysterical  spasm,  321 
Hystero-epilepsy,  586 


Ichthyosis,  614 
Icterus  gravis,  385 

neonatorum,  384 
Idiocy,  amaurotic  family,  564 
Impetigo  contagiosa,  603 
Infancy,  brain  palsies  of,  521 
Infective  diseases,  specific,  1 

sjilenic  enlargement  in,  179 
Influenza,  bacteriology  of,  35 

cardiac  complications,  37 

cerebral  form,  36 

chronic,  36 

course  of,  35 

diagnosis  of,  37 

differential  diagnosis,  24,  38 

gastro-intcstinal  symptoms. 
36 

incubation  period,  35 

nervous  disorders  in,  37 

otorrhea  in,  37 

respiratory  form,  35,  38 
Insolation,  199 
Intestinal  colic,  360 

obstruction, 

acute,  chnical  features, 

358 
complete  358 
partial,  357 


IXDEX 


629 


Intestinal  stasis,  355 
Intestines,  364 

diseases  of,  351 

special  forms,  363 

enteric  complications  in,  17 

tuberculosis  of,  98 
Intra-cranial  tumours,  523 
Intussusception,  acute,  365 
Iritis,  gononhoeal,  33 

in  secondary  syphilis,  71 
Itch  mite,  616 


Jacksoniax  epilepsy,  574 
Jaundice,  catarrhal,  383 
causes  of,  382,  398 
epidemic,  384 

infective,  of  newly-born,  385 
•Tenner's  staining  method,  155 
Jews,  amaurotic     family    idiocy 
among,  564 
diabetes  among,  185 
erythromelalgia    among, 
583 
Joints  affected  in  rheumatic  fever, 
59 
Charcot's,   in    tabes   dor- 

salis,  546 
gonorrhoeal,  33 
hysterical,  588 
inflammation  of,  195 
in  iheumatic  fever,  59 


Kala-azar,  clinical  features  of, 
123 
diagnosis  of,  124 
Keratitis,  interstitial  in  syphilis, 

74 
Kf-rion,  615 
Kernig's    sign    in    cerobro-spinal 

nicningitis,  6 
Kidney,  arteriosclerotic,  448,  452 
cortex,  massive  necrosis  of, 

457 
cystic  disf'aso,  463 
(h'gciM'rution  of,  453 
fatty  degeneration  of,  453 
function,  estimation  of,  464 
granular  degeneration,  454 
red,  446,  451 
white,  448,  452 
internal  scu-retion  of,  459  . 
larilaeeous  disease,  453 
mottled,  large,  446 
ni(»val)le,  461 


Kidney,  tuberculosis  of,  102 
tumours  of,  179 

characteristics  of,  461 
new  growths,  463 
malignant,  464 
and  urinary  apparatils,  dis- 
eases of,  442 
vascular  disturbances  of,  454 
white,  large,  445,  450 
Klebs-Lceffler  bacillus,  0,  13 
Knee-jerks,  impairment  in  tabes 

dorsalis,  547 
Koch's  old  tuberculin,' in  diag- 
nosis of  tuberculosis,  106 
Koplik's  spots  in  meaflles,  39,  41 
Korsakow's  syndrome,  509 


Labyrinthitis,  502 
Lactic  acid,  325 

tests,  330 
Landouzy-Dejerine  facio-scapulo- 
humeral  type  of  dystrophy,  561 
Landry's  paralysis,  559 
Lardaceous   disease   in   syphilis, 
73,  74 

of  kidney,  453 
Laryngeal  tuberculosis,  88 

ditferential  diagnosis  of,  88 
Laryngismus  stridulus,  286 
Laryngitis,  acute,  284 
"^  chronic,  285,  319 

in  measles,  40 

in  small-pox,  68 

simple,  chronic,  88 

spasmodic,  285 

syphilitic,  88 
Larynx,  carcinoma  of,  89 

diphtheria  of,  10 

diseases  of,  284,  286 

gumma  of,  72 

oedema  of,  285 
Lead  ])oisoning,  163,  204 

diagnosis  of,  205.  509 
Leg,  muscular  atrophy  of,  562 
Leg  tics,  581 

Leishman-Donovan  bodies,  123 
Leishman's  staining  m(>thod,  155 
Lentigo.  592 
Leoiitiasis  ossea,  182 
Leprosy,  bacteriology  of,  124 

course  of,  125 

diagnosis  of.  126 

incubation  ]ieriod  in,  125 

varieties,  125 


630 


INDEX 


Leucin  and  tyi'osin,  crystals  of, 

435 
Leucocytes,  eosinophile,  151 
polymoipliouuclear,  lol 
Leucocytosis,  causes  of,  159 

in  cerebro -spinal  meningitis, 

5 
in  leukaemia,  160 
Leucodermia,  593 
Leucopenia,  160 

in  yellow  fever,  138 
Leukaemia,  164 
blood  in,  164 
leucocytosis  in,  160 
lymphatic,  102 

acute  form,  165,  168 

blood  in,  165 
chronic  form,  165 
blood  in,  165 
myelogenous,  164 
pseudo-,  165 
spleno-medullary,  164 
Leukansemia,  166 
Lichen  planus,  610 

differential  diagnosis  of,  604 
Lichen  ruber  acuminatus,  608 

planus,  603 
Limping,  582 
Liver  abscess, 

multiple,  388 
single,  388 
signs  of,  388 
symptoms  of,  388 
actinomycosis  of,  1,  2 
cirrhosis  of,  177,  389 
biliary,  392 
multilobular,  390 
course  of,  392 
diagnosis  of,  391 
differential  diagno- 
sis of,  392 
morbid  anatomy  of 
390 
obstructive  biliary,  395 
pericellular,  394 
congestion  of,  388 
active,  389 
passive,  388 
functions  of,  380 
glycogenic  function  of,  187 
gumma  of,  72 
new  growths  of,  394 
diagnosis  of,  395 
symptoms  of,  395 
in  relation  to  renal  growths, 
462 


Liver,  yellow  atrophy  of,  acute, 

385 

diagnosis,  386 

symptoms,  386 

Locomotor  ataxy,  544 

Louse,    clothes    and    head    and 

pubic,  617 
Lumbago,  198 

Lumbar    puncture    in    cerebro- 
spinal meningitis,  6 
diagnostic  uses,  512 
Lungs,  abscess  of,  301 

in  pneumonia,  48 
actinomycosis  of,  2 
anatomy  of,  271 
in  bronchiectasis,  293 
collapsed,  307 

differential  diagnosis  of, 
308 
diseases  of, 

differential      diagnosis,  • 

51,  53 
vocal  fremitus  in,  275 
fibrosis  of, 

causes  of,  294 
diagnosis  of,  295 
physical  signs,  294 
gangrene  of,  49,  302 
gumma  of,  72 
new  growths  of,  295 
ojdema  of,  302 
tuberculosis  of,  84 
anatomy  of,  91 
broncho  -  pneumonia, 

acute,  90 
diagnosis  of,  92 
lever  in,  94 
fibro-caseous,  91 
fibroid,  96 
haemoptysis  in,  92 
lobar-pneumonia,  acute, 

89 
physical  signs  of,  95,  97 
pneumonic,  54 
sputum  in,  93 
symptoms  of,  92,  97 
Lupus  erythematosus,  596,  604 

vulgaris,  104,  605 
Lymphadenoma, 

clinical  features,  169 
diagnosis  of,  170 
mediastinal,  297 
Lymphatic  glands, 

secondary  syphilis  affecting, 

70 
tuberculosis  of,  101 


INDEX 


631 


Lymphocytes,  152,  165 
Lymphocytic  effusions,  tubercu- 
lous, 311 
Lymphosarcoma,  102 
Lyssophobia,  29 


Macule,  definition  of,  591 
Malaria,  sestivo-autumnal     form 
of,  126,  129 

clinical  features  of,   128 

diagnosis  of,  129,  131 

differential  diagnosis  of,  24, 
120,   123,  226 

febrile  stages  of,  128 

parasitology  of,  126 

quartan  form  of,  126,  128 

staining  films  for,  130 

tertian  form  of,  126,  128,  130 

varieties  of,  126 
Malignant  pustule,  3,  26 
Mallein,  32 
Malta  fever,  bacteriology  of,  132 

course  of,  132 

incubation  i)eriod  in,  132 
Meals,  test,  analysis,  327 

conclusions  drawn  from,  332 

examination  of,  329 

standard,  328 
Measles,  bacteriology  of,  38 

bronchitis  in,  40 

complications  of,  40 

course  of,  38 

diagnosis  of,  40 

differential  diagnosis,  41,  113 

incubation  ])criod,  38 

laryngitis  in,  40 

rash  in,  39 

varieties  of,  40 

Scr  also  (Jcinian  measles. 
Mediastinal  lympliadenoma,    2!t7 

tumour,  295 
Mediastinitis,  adhesive,  261 
Mediastinum,  new  growtli  of,  269 
Mediterranean  fever, 

bacteriology  <d',  132 

course  of,    132 

in<-iil>:ition  ]M-riod  in,  1.32 
Megaloblasts,   158,    1()3 
Melanin  in  urine,  410 
Membranes,  serous,  tuberculosis 

(»r,  99 
Menienrs  disease,  502 
Meningitis,  cerebrospinal, 

abortive  form,  5 
diagnosis  of,  5 


Meningitis,  abortive  form,  diffe- 
rential diagnosis  of, 
7,  68 
epidemic  form,  6 
intermittent  form,  5 
lumbar  puncture  in,  6 
malignant  form,  5 
posterior  basic,  5 
septic,  7 

sporadic  form,  5 
tuberculous,  6 
Meningitis,  in  pneumonia,  50 
tuberculous,  85 
course  of,  86 
stages  of,  87 
Meningomyelitis,  syphilitic,  543 
Mental  condition  in  chorea,  570 
in  epilepsy,  577 
symptoms    in    brain    tu- 
mour, 524 
of  chronic  alcohol- 
ism, 2(»1     ' 
Mercurial  poisoning,  168 

chronic,  206 
Mesenteric  glands, 

tuberculosis  of,  101 
tuberculous  storm  in,  23 
Metabolism,  380 
Meteorism  in  enteric  fever,  18 
Micrococcus  melitensis,  132 
Migraine,  278,  580 
aura  in,  579 

relationship  to  epilepsy,  579 
Milium,  593 
Mobius'     sign    in    exophthalmic 

goitre,  174 
Molluscum  contagiosum,  ()13 
Mongolian  idiots,  174 
Moro's   inunction   tests   in    diag- 
nosis of  tuberculosis,  108 
Morphinism,  203 
Morv^an's  disease,  534 
Mos(juito,  malaria  conveved  bv, 
I2() 
yellow    fever    convev«'d    bv, 
137 
Motion,  disorders  of,  569,  573 
Mucein  in  urine,  418 
Mucous    membranes,    sccinidarv 

sypliilis  atlVcling.  70 
Mumps,  bacteriology  of,  42 
course  of,  42 
diagnosis  of,  42 
dilYerential  diagnosis,  43 
inciil>ation  period,  42 
infective,  43 


632 


INDEX 


Muscles,  contractures,  hysterical, 
587 

electrical  reactions,  480,  483 

wasting  of,  in  children,  561 
Muscular  atrophy,     progressive, 
554,  562 

dystrophies,  560,  562 

Erb's  juvenile  type,  561 

function,  disorders  of,   566, 
568 

paralysis,        pseudo  -  hyper 
trophic,  560 

rheumatism,  197 

rigidity  in  paralysis  agitans, 
569 
Myalgia,  intercostal,  305 
Myasthenia  gravis,  566 

special  features,  567 
Myelitis,  acute,  533,  535 

ascending,  536 

transverse,  536,  543 
Myelocytes,  increase  of,  164,  166 
Myocardial  degeneration,  237 
Myotonia  atrophica,  565 

congenita,  565 
Myx oedema,  diagnosis  of,  172 

signs  and  symptoms  of,  172 


Nails,  inflammation  of,  71 

ringworm  of,  615 
Nausea  in  gastric  ulcer,  338,  341 
Neck  tics,  580 
Nematodes,  143 
Nephritis,  442 

acute,  complications,  443 
diagnosis  of,  444 
glomerular,  444,  450 
in  diphtheria,  13 
haemorrhagic,   chionic,   446, 

451 
histology  of,  449 
in  measles,  40 
morbid  anatomy  of,  449 
parenchymatous,  172,  446 
scarlatinal,  63,  444 
tub.al,  acute,  443,  450 
Nerves, 

cranial,  488 

eighth,  500 
eleventh,  503 
fifth,  496 

ninth  and  tenth,  502 
seventh,   497 
twelfth,  503 
facial,  497 


Nerves,  oculo-motor,  490 
olfactory,  488 
optic,  488 

peripheral,  lesions,  483,  562 
sensory,    segmental     distri- 
bution, 483 
spinal,  damaged,  symptoms 
due  to,  538 
Nervous  disorders    in    influenza, 
37 
diseases,  tongue  in,  315 
system,  anatomy  of,  468,  474 
central,  tracts  in,  468 
in  diabetes,  187 
lesions  of,  481 
motor  path,  469 
physiology  of,  468,  475, 

480 
sensory  path,  470,  472 
syphilitic  diseases  of,  72, 
541 
Neuralgia,  trigeminal,  497 
Neurasthenia, 

differential  diagnosis,  590 
symptoms,  589 
types,  590 
Neuritis,  brachial,  507 
in  beri-beri,  116 
gonorrhoea],  34 
interstitial  diagnosis,  505 

symptoms,  505 
optic,  489 

in  brain  tumours,  524 
parenchymatous,  508 
peripheral,  in  leprosy,  125 
toxic,  508,  510 
Neuron  sj^stem,  lesions  of,  481 
Neuroses,  gastric,  350 

occupation,  573 
Nitrobenzol  poisoning,  163 
Nitrogenous    bodies     in     urine, 

411,  413 
Nodule,  definition  of,  591 
Normoblasts,  158,  163 
Nose,  diphtheria  of,  10 

discharges    from    in    glan- 
ders, 30 
necrosis  of,  72 
Nystagmus,  causes  of,  494 
in  cerebellar  tumour,  527 
in  Friedreich's  disease,  563 


Occult  blood  test,  331 
Occupation  neuroses,  573 
(Edema,  angio-neurotic,  583 


INDEX 


633 


QEdema  of  larynx,  285 
(Esophageal    obstruction,     diffe- 
rential diagnosis,  321 

pouches,  320 

varix,  320 
Ointment,  Moro's,  108 
Omodynia,  198 
Ophthalmoplegia,  492 
Oijhthalmo-tuberculin    reaction, 

Calmette's,  107 
Ojjisthotonos,  79 
Opsonic    index    in    tuberculosis, 

108,311 
Optic  atrophy,  490 

neuritis,  489 
Orthopnoea,  274 
Osteitis  deformans,  181 
Osteo-arthritis,  196 

non-articular,  acute,  197 
Osteo -arthropathy, 

hypertropliic-pulmonary,182 

pulmonary,  292 
Osteomyelitis,  CO 
Otitis  media  in  diphtheria,  12 

in  scarlet  fever.  62 
Otorrhoea  in  influenza,  37 
Ovarian  cyst,  372 
Oxalate  of  lime,  crystals  of,  432 
Oxalates  in  urine,  432 
Oxy butyric  acid  in  urine,  431 
Oxyuris  vermicularis,  144 


Pachtmeningttis,  spinal,  542 

Paget's  disease,  181 

Pain  in  aortic  aneurysm,  264 

in  gastric  disease,  338 

in  neuritis,  506 

in  j)Ieurisy,  306 

in  tabes  dorsalis,  545,  547 
Palpation  in  tuberculosis,  95 

of  chest,  275 
I'alsies,  ccreliral,  acquired,  522 

craft,  573 

of  infancy,  521 
Pancreas,  cystic  tumours  of,  400 

diseases  of,  400 

fibrosis  of,  ISO 

solid  tumours  of,  407 

tumours  of,  400 
Pancreatitis,  clironic,  402 

Cammidgc's     test     for, 
403 

dinVrential  diagnosis,  40l 

hiemorrliagic,  a<'ute,  400 

non-h:emorrliagic,  acute,  402 


Papule,  definition  of,  591 
Paracentesis  in  pericarditis,  260 

thoracis,  309 
Paramvoclonus    multiplex,    567, 

572,  581 
Paralysis,  agitans,  206,  569 

Brown-Sequard's,  473 

bulbar,  555,  567 

cerebral  thrombosis  causing, 
517 

extent  of  in  paraplegia,  519 

facial,  499 

flaccid,  hysterical,  586 

general.     »SVe  General  para- 
lysis. 

muscular,      pseudo  -  hyper  - 
trophic,  560 

oculomotor,  491 

post-diphtheritic,  12 

spastic,  518,  535 

with  stiffness,  hysteric^,  586 
Paraphasia,  579 
Paraplegia,  194 

spastic,  familial,  564 
Parasites,  animal,  140,  150 

intestinal,  163,  353 
Parasitic   affection   of   the  skin, 

614 
Parasitology  of  malaria,  126 
Parasyphilitic  affections,  72,  77 
Para-typhoid  infection,  differen- 
tial diagnosis  of,  24 
Parkinson's  disease,  569 
Parotid  endotlielioma,  43 
Parotitis.     See  Mumps. 
Pavy's  solution,  428 
Pectoriloquy,  280 
Pediculosis,  178 
Pediculus  capitis,  617 

corporis,  1 11 

pubi.s,  617 

vestimentorum  ant  corporis, 
617 
Pellagra,  course  of,  605 
Pelvic    type    of    muscular    dys- 
trophy, 562 
Pemphigus  foliacus,  606,  607 

vegetans,  606,  607 

vulgaris,  606,  607 
Pepsin,  325 

tests,  330 
Percussion  of  chest,  276 

in  ])neumoniji,  46 

of  stomach,  324 

in  tuberculosis,  95 
Pericardial  friction,  217,  260 


634 


INDEX 


Pericarditis,  306 

acute,  differential  diaanosis, 

300 
effusion  in,  259 
fibrinous,  pliysical  signs   of, 
258 
symptoms  of,  258 
in  pneumonia,  49 
in  rheumatism,  58 
increase  of  dulness  in,  259 
suppurative,  261 
Pericardium, 

adherent,  210,  211 
groups  of,  261 
physical  signs,  262 
symptoms  of,  262 
affections  of,  258,  262 
Perinephric  abscess,  462 
Peritoneum,  diseases  of,  370 
Peritonitis,  acute,  374 
chronic,  278 
generalised,  375,  377 
in  pneumonia,  50 
localised,  377 
septic,  acute,  100 
tuberculous,  1 00 
Peritonsillar  inflammation,  317 
Peroneal  muscular  atrophy,  562 
Pes  cavus  in  Friedreich's  disease, 

563 
Pestis  major,  133 
minor,  133 
Pharyngitis,  acute,  318 

chronic,  319 
Phloridzin,  injection  of,  465 
Phthisis.       See    Lungs,     Tuber- 
culosis of. 
Pica,  351 
Pigeon  chest,  273 
Pigmentation,     causes    of,    176, 

l78 
Pirquet.     See  Von  Pirquet. 
Pituitary  body,  diseases  of,  181 

parts  of,  182 
Pityriasis  rosea,  608 
rubra,  607,  610 
rubra  pilaris,  608 
Plague,  bacteriology  of,  133 
bubonic,  133 
clinical  features  of,  133 
diagnosis  of,  135 
incubation  period  in,  133 
pneumonic,  133,  134 
septicsemic,  133,  135 
varieties  of,  133 
Plasmodium,  126 


Pleura,  effect  of  mediastinal  tu- 
mour on,  296 
Pleural  effusion, 

bacteriology  of,  310 
differential  diagnosis,  of,  52, 

308 
examination  of  fluid,  310 
paracentesis  thoracis,  309 
simple,  classical  signs,  306 
simple,  symptoms,  300 
Pleurisy, 

diagnosis  of,  99 
differential  diagnosis  of,  52 
dry,  diagnosis  of,  305 

symptoms  of,  304 
in  pneumonia,  49 
primary,  304 
secondary,  304 
tuberculous,  99 
Pleuritic    pain    in    lobar    pneu- 
monia, 45,  46 
Pleurodynia,  198,  305 
Pleuro-pericardial    friction,  217, 

260 
Plumbism,  204 

chronic,  163 
Pneumococcus,  297 
Fraenkel's,   43 
Pneumonia, 

apical,  47,  50 
asthenic,  48 
basal,  47 
central,  47 

complicating  influenza,  36 
double,  47 

lobar,  abdominal,  conditions 
in,  54 
abscess  of  lung  in,  48 
arthritis  in,  49 
bacteriology  of,  43 
complications  of,  local, 
48 
metastatic  or  septi- 
caemic,  49 
course  of,  45 
diagnosis  of,  50 
differential      diagnosis, 

24,  51,  53 
empyema  in,  49 
gangrene  of  lung  in,  48 
incubation  period,  44 
meningitis  in,  50 
pericarditis  in,  49 
peritonitis  in,  50 
physical  signs,  46 
pleurisy  in,  49 


INDEX 


635 


Pneumonia,  lobar,  pneumococcal, 
90 
sputum  in,  51 
ulcerative    endocarditis 

in,  49 
varieties  of,  47 
migratory  or  creeping,  47 
septic,  297 
terminal,  47 
Pneumonic  plague,  13  3 
Pneumonokoniosis,  291 

cause  of  fibrosis  of  lungs,  294 
Pneumothorax, 
causes  of,  311 
diagnosis  of,  313 
physical  signs  of,  312 
symptoms  of,  312 
Poikilocytosis,  163,  164 
Poisoning,  acute,  gastritis  from, 

337 
Polariscope,  427 
Poliomyelitis,  acute,  533,  557 
Polychromatophilia,  163,  164 
Polygraph,  238 
Polyuria  in  diabetes,  187,  189 
in  renal  tuberculosis,  103 
Pomphus,  definition  of,  592 
Pons  varolii,  tumours  of,  526 
Pontine  haemorrhage,  516 
Portal  vein  obstruction,  373,  374 
Prurigo,  Hebra's,  609 

simple,  608 
Pruritus,  592 
Psilosis,  136 
Psoriasis,  594,  598 

diff(MC!itial  diagnosis  of,  610 
PsychastJK'nia,  590 
Psvchical    epileptic    phenomena, 

576 
Ptomaine  poisoning,  28,  363 
Pulsations  not  caused   l)y  apex 

beat,  210 
Pulse,  bigeminal,  220 
dicrotic,  219 
expansion  of,  219 
fre(|nencv  •>'>  21 S 
in  actrtic  aneurysm,  266 
in  heart  d!sejus(%  231 
in  pneumonia,  51 
in  taihycanlia,  251 
in  tul»erciiiosis,  !t4 
katacrotic,  220 
quality  of,  219 
radiafwave.  220.  232 
rajtid,    in      broncho  -  pneu- 
monia, 299 


Pulse,  size  of,  219 
tension  of,  219 
venous,  221 
wiry,  219 
Pulsus  alternans,  254 
paradoxus,  220 
Pupil  changes  in  general  paraly- 
sis, 549 
in  tabes  dorsalis,  544 
dilatation  of  in  pleurisy,307 
light  reflex,  495 
Purpura,  diagnosis  of,  167 
fulminans,  167 
haemorrhagica,  166 
hsemorrhagica  pustulosa,  68 
Henoch's,  166 
rheumatica,  166 
simplex,  166 
variolosa,  67 
Pustule,  definition  of,  592 
Pyaemia,  60  / 

Pyaemic  lung  abscess,  301 
Pyelitis,  acute  primary,  455,  457 
chronic,  456 

calculous,  454 
Pyelonejjhritis,  445 
acute,  450 
Pylephlebitis,  386 
adhesive,  386 
suppurative,  387 
Pylorus,  new  growths  of,  346 
spasm  of,  345 

stenosis  of,  congenital  hyper- 
trophic, 345 
tumours  of,  323 
Pyonephrosis,  463 
Pyo-])ericardium,  261 
Pyorrluea  alveolaris,  315 
Pvuria,  425 


Quartan  fever,  126,  128 
Quinsy,  317 


K.\iui>  animals,  bites  of.  28 
Rachitis,  effect  on  chest,  273 
Rales,  281 
Rash  in  measl»>s,  3!t 

in  small-i)ox,  67 
Rashes,  drug,  28,  612 
Raynaud's  disease,  582,  583 
Recklinghausen.      See   Von 

Recklinghausen 
Rectum,  stricture  of,  72 


636 


INDEX 


Reflexes,  action,  475 

cerebellar,  474 

deep,  477 

in  chorea,  571 

in  hysteria,  587 

in  tabes  dorsalis,  546 

plantar,  476 

superficial,  476 
Relapsing  fever,  139 

bacteriology  of,  55 

complications  of,  56 

course  of,  55 

incubation  period,   56 

diagnosis  of,  56 
Renal  function,  estimation  of,  464 
Respiration,  Cheyne- Stokes,  275 

disorders  of,  274 

rapid,     in     broncho  -  pneu- 
monia, 299 

rate  and  types  of,  273,  274 

soimds,  278,  281 
Respiratory      complications      of 
whooping-cough,  114 

form  of  influenza,  35,  38 
Retinal  haemorrhages,  443 
Retro -peritoneal  sarcoma,  462 
Retropharyngeal  abscess,  origins 
of,  319 
glandular     ab- 
scess, 318 
Rheumatic  fever, 

bacteriology  of,  56 

cardiac  manifestations,  59 

complications  of,  58 

course  of,  156 

diagnosis  of,  58 

differential  diagnosis,  60 

endocarditis  following,  222 

manifestations  of,  57 

special  features  of,  59 
Rheumatic  nodules,  57 
Rheumatism, 

acute.    See  Rheumatic  fever. 

cerebral,  58 

manifestations  of,  57 

muscular.  See  Fibrositis. 

subacute,  33 
Rheumatoid  arthritis,  195 
Rhonchi,  280 
Ribs,  beading  of,  273 
Rickets,  bony  changes  in,  193 

diagnosis  of,  194 

etiology  of,  193 

general  symptoms  of,  193 

special  signs  of,  193 

See  also  Scurvy  rickets. 


Riegel's  test  meal,  328,  330 
Rigors  in  osteomyelitis,  60 

rare  in  rheumatic  fever, 

56,  60 
Ringworm  of  beard,  615 

of  body,  615 

of  nails,  615 

of  scalp,  615 
Rinne's  test,  501 
Rivalta's  test,  310 
Rodent  ulcer,  105 
Rothera's  test  (Garrod's  modifi- 
cation), 430 
Round-worms,  143 


Sahli,    on    acidity    of    stomach 

contents,  333 
Scabies,  616 

Scalp,  ringworm  of,  615 
Scarlet  fever,  602 
arthritis  in,  60 
bacteriology  of,  61 
complications  of,  62 
course  of,  61 
diagnosis  of,  63 
differential  diagnosis  of,  14, 

41,  64 
nephritis  in,  63,  444 
rash  in,  62,  64 
varieties  of,  62 
Schoenlein's  disease,  166 
Schwabach's  test,  501 
Sciatica,  506 
Scleroderma,  583 
Sclerosis,  disseminated,  543 

amyotrophic  lateral, 

553,  555 
differential      diagnosis, 

552,  554 
progressive,  563 
Scoliosis  in  Friedreich's  disease, 

563 
Scotoma,  579 
Scurvy,  167,  194 

diagnosis  of,  168 
rickets,  168 
symptoms  of,  168 
Sebaceous   glands,    disorders   of, 

593 
Seborrhoea,  594 

corporis,  608 
Secretions,  gastric,  325 

disorders  of,  349 
Sensations,  groups  of,  470 
loss  of,  534 


INDEX 


637 


Septicaemia,  167 

differential  diagnosis  of,  23 
erythematous  eruptions   of, 
42 
Septicaemic  plague,  133,  135 
Serum  globulin,  422 
Sexual  characteristics    in    hypo- 
pituitarism, 184 
organs,  in  diabetes,  188 
Shiga's  bacillus  dysentericus,  121 
Shingles,  602 
Shoulder  muscles,   weakness  of, 

567 
Skin,  actinomycosis  of,  3 
diseases  of,  591 

differential     diagnosis, 
598 
eruptions  in  rheumatism,  58 
functions    of,    disorders    of, 

592 
in  diabetes,   187 
new  formations,  612 
organic  diseases  of,  595 
parasitic  diseases  of,  614 
toxic  diseases  of,  595 
tuberculosis  of,  102,  104 
Skodiac  resonance,  277 
Sleeping  sickness, 

clinical  features  of,  135 
diagnosis  of,  136 
Small-pox,  32 

bacteriology  of,  66 

complications  in,  68 

confluent,  67 

course  of,  67 

differential    diagimsis   of,    8, 

41,  65,  68,  113 
ha;morrhagic,  67 
in  the  vaccinated,  8 
incubation  ])enod  in,  67 
ordinary,  67 
varieties  of,  67 
Smell,  disorders  of,  488 
"  Snuffles  "     in     congenital     sy- 
philis, 73 
Sore  throat  in  rheumatism,  57 
Sounds,  pernissioii,  276 
Speech  in  cerebellar  ataxia,  564 
in  Friedreich's  disease,  563 
centre,    lesions  of,    530,   532 
tics,  581 
Spinal  accessory  nerve,  503 
Spinal  cord,  473 

compression    of,    signs    and 

symptoms.  538 
diseases  of,  533 


Spinal  cord,  lesions  of,  481 
sclerosis  of,  162 
subacute    degeneration     of, 

combined,  556 
tumours  of,  535,  537 

differential      diagnosis, 
539 
Spine,  diseases  of,   diagnosis  of, 
537 
hysterical,  588 
local  disease,  539 
Spirillum  Obermeieri,  55 

of  cholera,  1 18 
Spirochaites,  73,  76 
Spleen, 

differential      diagnosis      of, 

179 
diseases  of,  178 
enlarged  in  Kala-azar,  123 
enlargements  of, 

causes  of,  179,  180 
great,  180  , 

moderate,    180 
slight,  179 
in  relation  to  renal  growtlis, 
462 
Splenic  anaemia,  169 

fever,  4 
Spondylitis  deformans,  197 
Spondylose  rhizomelique,  197 
Sporo-trichosis,   32 
"  Spotted  fever,"  5 
Sprue,  136 

Sputum,  examination  of,  282 
in  bronchiectasis,  292 
in  imeumonia,  51 
in  tul»erciilosis,  81,  93 
Staining  blood  lilms,  155 
films  for  malaria,  130 
Staphylococci  in  blood,  158 
Status  epilepticus,  576 

lymphaticus,  176 
Stellwag's  sign  in  exophthalmic 

goitre,  174 
Still's  disease,  196 
Stokes -A  dams  syndrome,  244 
Stomach, 

absorptive  power  of,   334 
acidify  of  contents,  329,  333 
anatomy  of,  322 
bacteriology  of,  331 
blood  in,  331 
cancer  (»f.    163.   179 

diagnosis  of,  338.  348 
signs     and     svmptome 
347 


638 


INDEX 


Stomach, 

contents,   microscopical  ex- 
amination, 331 
dilatation  of,  334 

physical  signs  of,  344 
signs     and     symptoms, 
344,  345 
diseases  of,  349 

clinical  varieties  of,  335 
diagnosis  methods,  325 
differential       diagnosis, 
338 
hyperacidity,  350 
hypersecretion,  349 
inflammation  of.     See  Gas- 
tritis, 
inspection  of,  323 
malignant  disease  of,  342 
motility  of,  333,  338 
new  growths,  symptoms  of, 

346 
palpation  of,  323 
paralytic  distension  of,  343 
percussion  of,  324 
physical  examination  of,  323 
secretions  of,  325 

disorders  of,  349 
splash,  324 
ulcer  of,  323 

course  of,  340 
diagnosis  of,  338 
differential  diagnosis  of, 

342 
etiology  of,  339 
haemorrhage  in,  342 
perforating,  340 
signs     and    symptoms, 

341 
situation  and  varieties 

of,  340 
symptoms  and  signs  of, 

341 
vomiting  in,  326 
Stomatitis,  gangrenous,  316 

ulcerative,  316 
Strabismus,  492 
Streptococcic  sera,  61 
Streptococcus  pyogenes,  25 
Streptothrix  organism,  1 
Stridor,  obstructive,  275 
Strychnine  poisoning,  80 
Subphrenic  abscess,  377 
Sugar  in  blood  in  diabetes,  185 
in  urine,  quantitative  esti- 
mation of,  428 
toleration  of,    186 


Sulphates  in  urine,  433 
Sunstroke,  199 
proper,  199 
Suprarenal  bodies,    diseases    of, 
176 
secretion,  187 
Swallowing,  difficulty  in,  320 
Sweat  glands,  disorders  of,  595 
Sweats,  night,  92 
Sycosis,  611 
Syncope  from  exhaustion,  199 

local,  582 
Synovitis,  chronic,  in  syphilitis, 

74 
Syphilides,  cutaneous,   in  secon- 
dary syphilis,  70 
pustular,  68 
Syphilis,  321,  610 

bacteriology  of,  69 
cerebro -spinal  diffuse,  541 

localised,  542 
congenital,  73,  168,  173,  194 
diagnosis  of,  75,  77 
Hutchinson's   teeth   in, 

73 
manifestations  of,  73,  74 
course  of,  69 
diagnosis  of,  74,  321 

special  methods  in,  75 
of  nervous  system,  541 
primary,  69 
secondary, 

cutaneous  syphilides  in, 

70 
diagnosis  of,  74 
lymphatic     glands     af- 
fected, 70 
manifestations  of,  71 
miicous  membranes  in- 
volved, 70 
tertiary, 

alimentary    system    in, 

72 
circulatory    system    in, 

71 
diagnosis  of,  74 
nervous  system  in,  72 
periostitis  in,  71 
respiratory    system    in, 
72 
tongue  in,  315 
ultra-microscope     in     diag- 
nosis of,  75 
varieties  of,  69 
Wasserraann's     reaction    in 
diagnosis  of,  75,  76 


INDEX 


639 


Syringomyelia,     diagnostic    fea- 
tures, 534 

Tabes  dorsalis,  72 

diagnosis  of,  547 

juvenile,  547 

manifestations 

by  cranial  nerves,  544 
by  motor  system,  545 
by  sensory  system,  545 

reflexes  in,  546 

signs  of,  547 

trophic  changes,  546 

visceral  crises  in,  546 
Tachycardia,  ])aroxysmal,  simple, 

248 
Toinia  echinococcus,  142 

saginata,   140 

solium,  141 
Tanners,  anthrax  in,  3 
Tapeworms,  140 
Teichopsia,  579 
Temperature  in  relapsing  fever, 

55 
Tertian  fever,  126,  128,  130 
Test  meals, 

analysis  of,  327 

conclusions  drawn  from,  332 

examination  of,  329 

standard,  328 
Tests  for  albumin,  419,  422 
Tetanus, 

bacteriology  of,  78 

cephalic,  79 

chronic,  79 

course  of,  79 

diagnosis  of,  80 

hydro])lu)bia    mistaken    for, 
29 

idiopathic,  79 

incubation  j)eriod  in,  79 

neonatorum,  79 

varieti<'s  of,  79 
Tetany,  80,  572 
Tlioiiia  -  Zeiss     htcmocytometer, 

153 
Thomsen's  disease,  565 
'^riiread  worms.   144 
Trimetliylamine,  459 
Throat,  sore,  in  rlieumafism,  57 
in  secondary  svj)iiilis, 
70 
Tln<>nil)osis,  cerebral,  516 

enteric  fever,  18 
'I'liymus,  diseases  of,  175 
riiyroid  extract,  173 


Thyroid  gland,  572 

diseases  of,  172 
Thyroidectomy,  myxcedema  fol- 
lowing, 172 
Tics,  various,  580 
Tinea  barba?,  615 

circinata,  615 
favus,  616 
tonsmans,  615 
unguium,  615 
versicolor,  616 
Toisson's  solution,  153,  155 
Tongue,    conditions    in    disease, 

314 
Tonsillitis, 

follicular,  316 

differential    diagnosis, 
14,  65 
gangrenous,  315,  318 
parenchymatous,  317 
Tonsils,  abscess  of,  317 
Torticollis,  198  / 

Ti-acheal  tug  in  aortic  aneurysm, 

266 
Trematodes,  149 
Tremors,  hysterical,  587 

in  paralysis  agitans,  570 
senile,  570 
of  tongue,  314 
Treponema  pallidum,  69,  75 
Trichina  spiralis,  145 
Trichiniasis,  symptoms  of,  145 
Trigeminal  neuralgia,  497 
Trismus,  80 

Trophic  diseases,  582,  584 
Tropical  liver  abscess,  388 
Trousseau's  sign  in  tetany,  572 
Try]>anosoniiasis,  135 
Tuberculin,  Koch's      old,      diag- 
nosis by,  106 
therapeutic  doses  of,  110 
Tuberculosis,  226,  291 
bacteriology  of,  81 
diagnosis  of, 

by    Calmette's        Oph- 
tlialino-tuberculin  re- 
action,  107 
determination      of     op- 
sonic^ index, 108 
by     liypodermic     injec- 
tion    of     Koch's    old 
tuberculin,  l<l(> 
bv     Moro's     inunction 

"tests.  108 
special  methods  in.  105, 
110 


